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‘Natural’ Disasters and Cancer Care Disruptions:

Perspectives from Providers in Puerto Rico Following Hurricane Maria

Genevieve S. Silva,1 Leyda Marrero Morales,2 Isabelle Do,3 Taylor Drew,4 Ana Velazquez-Manana,5 Hiram A. Gay,6 Katie E. Lichter7,8,9

​

1. Transitional Year Residency Program, Penn Medicine Doylestown; 2. University of California San Francisco (UCSF) School of Medicine; 3. University of Alabama at Birmingham Marnix E. Heersink School of Medicine, 4. Grant Medical Center, Columbus Ohio, 5. UCSF Division of Hematology-Oncology, 6. Department of Radiation Oncology, WashU Medicine, 7. Department of Radiation Oncology and Applied Sciences at Dartmouth Hitchcock Medical Center, 8. The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth Geisel School of Medicine, 9. School of Medicine, UCSF

Background

  • Cancer care delivery is vulnerable to extreme weather events, particularly in low-resource settings where prolonged recovery periods can amplify health inequities
  • Patients undergoing oncologic treatment, including chemoradiation, often require uninterrupted, time-sensitive treatment, making them especially susceptible to climate-related care disruptions
  • Puerto Rico, a U.S. territory with high environmental and social vulnerability, experienced widespread infrastructure damage following Hurricane Maria in 20171,2
  • While initial health impacts from the natural disaster have been documented, limited data exist on the long-term perspectives of oncology professionals regarding disaster preparedness, response, and patient impact

​

  • AIM: Here, we aim to assess the effects of recent extreme weather events on patient care and clinic operations, as experienced by oncology providers in Puerto Rico

Methods

  • Timeframe: October 2023 to January 2024
  • Participants: Radiation oncologists and medical physicists practicing in Puerto Rico
    • Identified through the American Society for Radiation Oncology directory and recruited with support from local collaborators
  • Design: Survey study evaluating climate disaster impacts on clinical operations
    • Survey instrument adapted from a previously-published survey tool evaluating wildfire-related disruptions to oncology care3
    • Survey refined through a 10-person pilot to ensure contextual relevance
  • Analysis:
    • Analyzed significant differences in perceived impact of natural disasters on patients vs. physicians/clinic staff
    • Evaluated frequency of reported operational clinic disruptions across sample
    • Clinic locations were geocoded and assessed in relation to the U.S. Census Bureau’s Community Resilience Estimates for Equity and to FEMA’s open aid database reflecting regional degree of aid received

Results

  • Sample: 10 participants (8 radiation oncologists, 2 medical physicists), representing 15 radiation therapy sites (response rate: 56%)
  • 90% of respondents reported extreme weather had directly impacted care delivery Most sites (70%) in census tracts with ≥3 high social vulnerability indicators
  • Greatest perceived burdens fell on patients: evacuations, food insecurity, & limited transportation (p<0.005)
  • Clinic operations were most affected by power outages & failures in communication infrastructure

Conclusions & Future Directions

  • Radiation oncology providers in Puerto Rico report significant and ongoing disruptions in cancer care delivery from climate-related disasters, underscoring the urgent need for robust, equity-focused preparedness strategies
  • Future efforts should incorporate: clinician and patient insights, community vulnerability data, and collaboration with professional societies to strengthen disaster resilience across oncology care systems

Acknowledgements

Thank you to our collaborators in PR. ____ XXX

For all study-related questions, please contact Dr. Katie Lichter: katie.lichter@ucsf.edu

​

1 PMID: 37066399, 2 PMID: 30999000, 3 PMID: 38304108

Figure 1. Distribution of Reported Climate Impacts on Radiation Oncology Clinics in Puerto Rico (2017-2024)

Radiation oncology clinics in Puerto Rico, color-coded by reported impact from climate disasters. Counties outlined in white. (A) Degree of social vulnerability (SV), per US Census Bureau’s Community Resilience Estimates for Equity (0, 1-2, and ≥3 components of SV). (B) Degree of total FEMA aid (USD) after Hurricanes Maria & Irma.

Table 1. Perceived and Self-Reported Impacts of Climate Disasters on Radiation Oncology Providers, Staff, and Patients

Dimension of climate disaster impact (n = 10)*

Perceived Patients Impacts (n, %)

Perceived Staff Impacts (n, %)

Self-reported Physician/Physicist Impacts (n, %)

P value**

Poor air quality

2 (20%)

1 (10%)

0 (0%)

-

Geographic relocation

4 (40%)

4 (40%)

0 (0%)

-

Community/regional evacuations

6 (60%)

2 (20%)

1 (10%)

< 0.001

Health issues (due to lung exposure to smoke, infectious disease, etc)

6 (60%)

2 (20%)

0 (0%)

-

Limited/no access to food

6 (60%)

4 (40%)

2 (20%)

< 0.005

Limited/no access to clean water

6 (60%)

5 (50%)

4 (40%)

> 0.05

Mental health burden(s)

6 (60%)

5 (50%)

3 (30%)

> 0.05

Temporary home evacuation

6 (60%)

5 (50%)

2 (20%)

< 0.005

Financial burden(s)

7 (70%)

6 (60%)

5 (50%)

> 0.05

Unable or advised to not to leave home

8 (80%)

7 (70%)

4 (40%)

< 0.05

Loss of communication with medical providers, patients, and/or colleagues

8 (80%)

9 (90%)

7 (70%)

> 0.05

Home/property damage

9 (90%)

9 (90%)

9 (90%)

> 0.05

Interruption of access to transportation/transportation services (e.g., public transit, personal vehicle, etc.), including damage to roads

9 (90%)

9 (90%)

7 (70%)

< 0.05

School and/or childcare closures related to the climate-fueled extreme weather event/emergency

9 (90%)

9 (100%)

8 (80%)

> 0.05

Loss of medical records

0 (0%)

-

-

-

Patient relocation and transfer of care to an alternative treatment facility/clinic

4 (40%)

-

-

-

Reduced access to medical supplies, devices, and/or pharmaceuticals

7 (70%)

-

-

-

Clinic or patient rescheduled appointment(s)

9 (90%)

-

-

-

Patient(s) missed appointment(s)

9 (90%)

-

-

-

Changed practice location(s) permanently

-

1 (10%)

0 (0%)

-

Considered early retirement and/or retired early

-

1 (10%)

1 (10%)

-

Moved homes permanently

-

2 (20%)

1 (10%)

-

Changed practice location(s) temporarily

-

3 (30%)

1 (10%)

-

Table 2. Consequences for clinic operation due to extreme climate event (n = 10)*

Other: Insurance Denial of coverage for damages caused

1 (10%)

Limited/no access to clean water

2 (20%)

Physical destruction of the clinic infrastructure (i.e. buildings, treatment machines, etc.)

3 (30%)

Unavailable medical supplies, devices, and/or pharmaceuticals

3 (30%)

Patient transfers

4 (40%)

Clinic closure(s)

6 (60%)

Financial burden(s)

6 (60%)

Staffing Shortages

6 (60%)

Interruption of communication systems (i.e. damaged phone lines and/or loss of internet)

8 (80%)

Power outage(s)

9 (90%)

*Nine respondents answered these prompts directly. An n of 10 is used to account for the one respondent who indicated they were unaffected by climate disasters. The darker the shade of red, the more highly endorsed that experience was by respondents.

*Nine respondents answered these prompts directly. An n of 10 is used to account for the one respondent who indicated being unaffected by climate disasters. **Pearson χ2 values identify the differences in values between perceived impact on patients and physician/physicists. Statistical significance cut-off of p=0.05. The darker the shade of red, the more highly endorsed that experience was by respondents.

Results

  • 90% implemented an emergency preparedness plan
  • Plans viewed as most effective involved coordination with health departments & community-based organizations
  • 80% endorsed a stronger role for professional societies, particularly in patient education and financial support mechanisms

2 of 2

‘Natural’ Disasters and Cancer Care Disruptions:

Perspectives from Providers in Puerto Rico Following Hurricane Maria

Genevieve S. Silva,1 Leyda Marrero Morales,2 Isabelle Do,3 Taylor Drew,4 Ana Velazquez-Manana,5 Hiram A. Gay,6 Katie E. Lichter7,8,9

​

1. Transitional Year Residency Program, Penn Medicine Doylestown; 2. University of California San Francisco (UCSF) School of Medicine; 3. University of Alabama at Birmingham Marnix E. Heersink School of Medicine, 4. Grant Medical Center, Columbus Ohio, 5. UCSF Division of Hematology-Oncology, 6. Department of Radiation Oncology, WashU Medicine, 7. Department of Radiation Oncology and Applied Sciences at Dartmouth Hitchcock Medical Center, 8. The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth Geisel School of Medicine, 9. School of Medicine, UCSF

Background

  • Cancer care delivery is vulnerable to extreme weather events, particularly in low-resource settings where prolonged recovery periods can amplify health inequities
  • Patients undergoing oncologic treatment often require uninterrupted, time-sensitive treatment, making them especially susceptible to climate-related care disruptions
  • Puerto Rico, a U.S. territory with high environmental and social vulnerability, experienced severe infrastructure damage following Hurricane Maria in 2017 [1,2]

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​

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​

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​

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  • Limited data exist on the long-term perspectives of oncology professionals regarding disaster preparedness, response, and patient impact

​

  • AIM: Here, we aim to assess the effects of recent extreme weather events on patient care and clinic operations, as experienced by oncology providers in Puerto Rico

Results

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  • Sample: 10 participants (8 radiation oncologists, 2 medical physicists), representing 15 radiation therapy sites (response rate: 56%)
  • 90% of respondents reported extreme weather had directly impacted care delivery
  • Greatest perceived burdens fell on patients: evacuations, food insecurity, & limited transportation (p<0.005)
  • 80% of respondents endorsed a stronger role for professional societies, particularly in patient education and financial support mechanisms

1 PMID: 37066399, 2 PMID: 30999000, 3 DOI: 10.1007/s11111-020-00338-6, 4 PMID: 38304108

Results

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  • Clinic operations were most affected by power outages & communication disruptions
  • 90% implemented an emergency preparedness plan; most effective involved coordination with health departments & community-based organizations
  • 80% endorsed a stronger role for professional societies, particularly in patient education and financial support mechanisms

Methods

  • Timeframe: October 2023 to January 2024
  • Participants: Radiation oncologists and medical physicists practicing in Puerto Rico
    • Identified through the American Society for Radiation Oncology directory and recruited with support from local collaborators
  • Design: Survey study evaluating climate disaster impacts on clinical operations
    • Survey instrument adapted from a previously published survey tool [4]
    • Survey refined through a 10-person pilot to ensure contextual relevance
  • Analysis:
    • Pearson's χ2 tests for significant differences (p<0.05) in perceived impact of natural disasters on patients vs. physicians/clinic staff
    • Surveyed clinic locations were mapped according to US Census data on social vulnerabilities and to FEMA aid distribution

Peak gust wind speed and 48-hr total rainfall (in) from Hurricane Maria (Figure 1a, c) [3]

Dimension of climate disaster impact (n = 10)*

Perceived Patients Impacts (n, %)

Perceived Staff Impacts (n, %)

Self-reported Physician/Physicist Impacts (n, %)

P value**

Poor air quality

2 (20%)

1 (10%)

0 (0%)

-

Geographic relocation

4 (40%)

4 (40%)

0 (0%)

-

Community/regional evacuations

6 (60%)

2 (20%)

1 (10%)

< 0.001

Health issues (due to lung exposure to smoke, infectious disease, etc)

6 (60%)

2 (20%)

0 (0%)

-

Limited/no access to food

6 (60%)

4 (40%)

2 (20%)

< 0.005

Limited/no access to clean water

6 (60%)

5 (50%)

4 (40%)

> 0.05

Mental health burden(s)

6 (60%)

5 (50%)

3 (30%)

> 0.05

Temporary home evacuation

6 (60%)

5 (50%)

2 (20%)

< 0.005

Financial burden(s)

7 (70%)

6 (60%)

5 (50%)

> 0.05

Unable or advised to not to leave home

8 (80%)

7 (70%)

4 (40%)

< 0.05

Loss of communication with medical providers, patients, and/or colleagues

8 (80%)

9 (90%)

7 (70%)

> 0.05

Home/property damage

9 (90%)

9 (90%)

9 (90%)

> 0.05

Interruption of access to transportation/transportation services (e.g., public transit, personal vehicle, etc.), including damage to roads

9 (90%)

9 (90%)

7 (70%)

< 0.05

School and/or childcare closures related to the climate-fueled extreme weather event/emergency

9 (90%)

9 (100%)

8 (80%)

> 0.05

Loss of medical records

0 (0%)

-

-

-

Patient relocation and transfer of care to an alternative treatment facility/clinic

4 (40%)

-

-

-

Reduced access to medical supplies, devices, and/or pharmaceuticals

7 (70%)

-

-

-

Clinic or patient rescheduled appointment(s)

9 (90%)

-

-

-

Patient(s) missed appointment(s)

9 (90%)

-

-

-

Changed practice location(s) permanently

-

1 (10%)

0 (0%)

-

Considered early retirement and/or retired early

-

1 (10%)

1 (10%)

-

Moved homes permanently

-

2 (20%)

1 (10%)

-

Changed practice location(s) temporarily

-

3 (30%)

1 (10%)

-

Table 1. Perceived and Self-Reported Impacts of Climate Disasters on Radiation Oncology Providers, Staff, and Patients

*Nine respondents answered these prompts directly. An n of 10 is used to account for the one respondent who indicated being unaffected by climate disasters. **Pearson χ2 values identify the differences in values between perceived impact on patients and physician/physicists. Statistical significance cut-off of p=0.05. The darker the shade of red, the more highly endorsed that experience was by respondents.

Conclusions & Future Directions

  • Radiation oncology providers in Puerto Rico report significant and ongoing disruptions in cancer care delivery from climate-related disasters, underscoring the urgent need for robust, equity-focused preparedness strategies
  • Future efforts should incorporate: clinician and patient insights, community vulnerability data, and collaboration with professional societies to strengthen disaster resilience across oncology care systems

Acknowledgements

Thank you to our collaborators, Dr. Vanessa Marcial and Dr. Lawrence Sheplan in Puerto Rico.

For all study-related questions, please contact Dr. Katie Lichter: katie.lichter@ucsf.edu

​

Consequences for clinic operation due to extreme climate event (n = 10)*

(n, %)

Other: Insurance Denial of coverage for damages caused

1 (10%)

Limited/no access to clean water

2 (20%)

Physical destruction of the clinic infrastructure (i.e. buildings, treatment machines, etc.)

3 (30%)

Unavailable medical supplies, devices, and/or pharmaceuticals

3 (30%)

Patient transfers

4 (40%)

Clinic closure(s)

6 (60%)

Financial burden(s)

6 (60%)

Staffing Shortages

6 (60%)

Interruption of communication systems (i.e. damaged phone lines and/or loss of internet)

8 (80%)

Power outage(s)

9 (90%)

Table 2. Clinic operation impacts experienced due to climate-fueled extreme weather events occurring in the last 5 years

*Nine respondents answered these prompts directly. An n of 10 is used to account for the one respondent who indicated they were unaffected by climate disasters. The darker the shade of red, the more highly endorsed that experience was by respondents.

Figure 1. Distribution of Reported Climate Impacts on Radiation Oncology Clinics in Puerto Rico (2017-2024)

Radiation oncology clinics in Puerto Rico, color-coded by reported impact from climate disasters. Counties outlined in white. (A) Degree of social vulnerability (SV), per US Census Bureau’s Community Resilience Estimates for Equity (0, 1-2, and ≥3 components of SV). (B) Degree of total FEMA aid (USD) after Hurricanes Maria & Irma.