Written by Jeanie Bryant, coordinator of the Global Health Center at the Institute for Public Health
Hiram Gay, MD, professor of Radiation Oncology at Washington University in St. Louis, is lead author on the most downloaded article in 2020 in the journal, Practical Radiation Oncology. There’s a reason. The article, Lessons Learned from Hurricane Maria in Puerto Rico: Practical Measures to Mitigate the Impact of a Catastrophic Natural Disaster on Radiation Oncology Patients, which received 6,120 downloads in the journal, discusses how to handle delays in oncology treatment during natural disasters, like hurricanes – something the world deals with each summer as hurricane season wreaks havoc on our coastlines here and around the globe. Early in the COVID-19 pandemic this article became an important practice guide to clinicians internationally. We interviewed Dr. Gay about the impact of his “most downloaded” article:
Why do you think your article was the most downloaded manuscript in this journal?
As described in the editorial of Practical Radiation Oncology’s Top 20 Downloads of 2020, “The most downloaded article describes how radiation oncologists in Puerto Rico reacted to Hurricane Maria. This article became a seminal guide internationally during the initial phase (2019) of the coronavirus pandemic.” The article has a table (Table 3) which focuses on compensating for delays in radiation therapy for lung, cervical, head and neck, breast, and prostate cancer that is very useful for treatment delays and interruptions during the COVID-19 pandemic. The article is a large collaboration of many radiation oncologists in Puerto Rico and the U.S. and includes significant expertise that strengthened the publication.
Fact: Hurricane Maria made landfall in Puerto Rico on the morning of September 20, 2017, as a category 4 hurricane, with sustained winds of 155 mph.
In your manuscript you indicate that radiation oncologists throughout Puerto Rico collaborated and improvised to continue treating patients in the immediate aftermath of the storm. How were the radiation oncologists able to continue to treat patients?
Some were able to re-establish connections to the power grid, telecommunications, and water service faster than others were. The clinics that reestablished power first, were usually also able to be operational first. The clinic closest to Maria’s initial landfall, on the other hand, was dependent on a diesel generator for 140 days, which speaks volumes to the preparedness of the clinic since the generator was able to handle such demands. Communicating with patients was an incredible challenge since telecommunications were down and some roads were impassable. A clinic in one of the most affected areas went as far as going door-to-door to reach their cancer patients so they could resume treatment.
What framework was used to implement the practical measures needed to mitigate the medical impact of this disaster?
We named the radiation oncology framework PCOC: prepare, communicate, operate and compensate. Sounds like “peacock.” The “preparation” phase is critical in minimizing the treatment delays that may result from a natural disaster. The “communication” phase implements the communication plan to reach patients efficiently through any available means and minimize treatment delays. “Operate” means to resume radiotherapy services as soon as possible. Finally, “compensate” alludes to strategies specific to a given type of cancer to make up for treatment delays and interruptions.
How can any community become more resilient in preparing for a local or regional disruption from any cause?
The unprecedented Hurricane Maria disaster highlighted the vulnerability of a modern society to prolonged failures of the electrical grid, telecommunications, and fuel shortages. I had experienced hurricanes in Puerto Rico before, but had never seen a catastrophic failure of the infrastructure to this level and length of time with a lasting impact in some areas greater than a year. Preparing for the worst-case scenario will mitigate a disaster to continue to provide life-saving treatments to patients. Some clinics in Puerto Rico were remarkably prepared, while a small number lacked diesel generators to continue operating.
You work closely with the Global Health Center, Liga Nacional Contra el Cancer/Instituto Nacional de Cancerologia in Guatemala (LIGA/INCAN, a comprehensive referral cancer treatment center in Guatemala), Varian Medical Systems (Varian) and the National Nuclear Security Administration (NNSA) and helped build LIGA/INCAN into a Center of Excellence for delivery of radiation oncology services in Central America. Read more. How do the lessons learned from Hurricane Maria help with this partnership?
Fortunately, LIGA/INCAN has not faced a major natural disaster recently, but Guatemala has faced volcanic eruptions, earthquakes, and other natural disasters in the past. Guatemala’s limited radiotherapy (RT) resources means that strategies like hypofractionation (less number of RT treatments than longer conventional courses to cure patients) is an attractive strategy to be more efficient and treat more patients effectively. Hypofractionation is discussed in the article to mitigate treatment delays and interruptions, and the linear accelerator we installed through our collaboration has the modern technological capabilities to safely deliver hypofractionated courses.