Evolving Threats in Cybersecurity and Radiation Oncology: A Present Danger and a Call for Manuscripts

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.


  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 oncology6(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)
Posted: June 8, 2021 | 0 comments

A Q&A on Nutrition in Cancer: Evidence and Equality

By ASTRO Journals Team

A recent Advances in Radiation Oncology article, Nutrition in Cancer: Evidence and Equality, examines the role of nutrition in cancer through the lens of social equity. Focusing on how diet affects cancer outcomes, particularly patients living in food priority areas (FPAs), the researchers sought to collect data at the human cellular level to advance understanding of the link between poor nutrition and cancer. Their research concentrated on four areas: nutritional intervention, synergy with definitive treatments, diet and long-term effects and how a lack of nutrient-dense foods contributes to outcomes. To learn more about this research, we reached out to the corresponding author Melissa A.L. Vyfhuis, MD, PhD, to answer a few questions.

Please summarize your study.

Our article attempts to answer the question: How does diet affect cancer outcomes? We tried to answer the question with as much data as possible, including human population level epidemiology down to cellular signaling. All in all, we found over 100 years of evidence that dietary intake can affect tumor development, may enhance treatment effects and may prevent symptoms associated with muscle wasting. Despite this, there are few clinical trials to demonstrate evidence-based recommendations. The highest-risk populations — those at high risk of nutritional deficits at baseline — may have the most to gain from such dietary interventions, but there are no studies to date.

What initially prompted you to pursue this study?

Historically, the primary focus of dietary intervention in oncology was caloric density. Understandably, oncologists are focused on the prevention of weight loss. Indeed, most clinical studies in humans aim to minimize treatment interruptions from manifestations of cachexia. However, if obesity, insulin resistance and metabolic syndrome account for major risk factors in tumorigenesis — and are major causes of death following completion of curative oncologic therapies — then perhaps the individual baseline should be taken into consideration. Our research demonstrates that nuance in dietary recommendations may be beneficial.

Looking at the bigger picture, how could your findings impact patient care? What do you see as the key practice-changing implications of the research?

Approximately one third of patients ask what they should eat prior to embarking on definitive cancer therapies. We see four separate and important questions that need further research to provide patients with the best answer. First, can nutritional intervention (micronutrient or macronutrient supplementation) mitigate or prevent cachexia and therefore help patients complete definitive therapies? Second, is there a possible treatment related effect whereby nutrition can synergize with definitive treatments to increase control or survival? Third, can a healthy diet mitigate the long-term side effects of definitive cancer therapies? Finally, to what extent are patients with the highest nutritional deficiencies at baseline adversely affected from their lack of access to nutrient dense foods?

Did anything about your findings surprise you?

We were surprised to find just how far back in time the original nutritional intervention studies go.  Despite 100 years of animal data suggesting a treatment effect, we are still in need of large randomized trials across many disease sites and patient populations.

You point out that many studies have been published on the effects of living within an FPA and having higher incidences of various health issues like diabetes, hypertension, etc., but few studies have focused on cancer treatment and outcomes for patients living in FPAs. You then conclude that further research is needed to characterize the nutritional needs of cancer patients residing in FPAs and strategize how best to include them in future clinical trials. Why do you think this subject has not been studied as much as others regarding equity in health care, and what can cancer researchers do to include this population in future clinical trials?

I believe that this subject has not been studied as much because the prospective characterization of nutrition and its effect on cancer care is such a complicated, difficult task to begin unraveling, especially since other confounding factors can cloud the pictures such as access to care, social support and other psychosocial factors.

The recent addition of deregulated cellular energetics as an emerging hallmark of cancer highlights that the acceptance of the role in nutrition in cancer is also recent. We now hope to see this area of research grow rapidly.

What is the link between FPA and food deserts? Food deserts and poverty cannot be solved by health care practitioners alone, but what do you see as their role in decreasing the effects of living in these areas has on patients?

Patients living in FPAs (previously called food deserts) are at high risk of nutritional deficiencies because of lack of access; however, these zip codes can be very heterogenous. While community access to food cannot be solved by a health care professional, we hope to start a dialogue between oncology practitioners and patients. The end goal would be a discussion regarding the patient’s current diet, the recommended diet during and after a definitive cancer treatment and resources that can be used to bridge the gap. Hopefully, with these specific nutritional interventions, citizens at risk for poor eating habits can live longer, healthier lives after cancer care.

What steps can health care practitioners treating underserved populations living in FPAs take to improve nutrition, and therefore potentially improve outcomes, for patients?

We believe that asking patients about their current diet and access to nutritious foods is the best start.While future studies are needed, encouraging nutrient dense foods as opposed to calorically dense foods that are within each patient’s budget will likely be prudent. Also, having information on hand about resources available in the area (i.e. virtual pantry programs, church donations) to provide to patients can be helpful.

What are your next steps? Will you be pursuing further study?

Our next step is to better characterize our own patient population’s access to nutritious foods. In a prospective manner, we will gather data about our patient’s diets and economic means to determine how to best identify patients at the highest risk of nutritional deficits. We hope to begin to bridge the gap with those in the greatest need.

Read the full article, Nutrition in Cancer: Evidence and Equality in Advances in Radiation Oncology, ASTRO’s open-access journal.

Posted: July 1, 2020 | 0 comments

Reflections on a Decade at the Helm: Key Qualities of a Successful Red Journal Editor-in-Chief

By Anthony Zietman, MD, FASTRO

Ten years ago, I was chosen to become the editor-in-chief (EIC) of the Red Journal and, on reflection, I cannot believe how na├»ve I was entering the position, and how little I understood the qualities required to lead the journal well. I had a dreamy and romantic view that it was about reviewing some papers, making some great choices, and voila, as if by magic, quality would just shine out. What I did not realize was the level of 24/7 commitment required, the necessity to develop a dynamic and like-minded editorial team, the diplomatic stresses and the ethical, and even legal, challenges. Even though I had been chair of ASTRO previously, this position eclipsed that for its unique challenges. As my term concludes in 2021 and the search for my successor begins, I’ve been reflecting a lot on what it has taken to haul the Red Journal to where it is today and on what it will take for my successor to bring it to the next level. If you are considering the position, these are my tips.

The incoming editor-in-chief should be:

  • A time management marvel. This journal moves very fast. With 15 issues per year and hundreds of pages per issue, there is always work to be done. Often this work cannot wait more than a day or two. The journal occupies nights and weekends and pops up between patients in clinics…every day.
  • Dedicated to the journal. Along the lines of the above, the new editor should have a proven commitment to the journal, likely through editorial responsibilities, reviewing and/or writing. Because of the volume of work, the personal investment and the especially nuanced judgment required of this role, you’ll need to love the Red Journal — well before you apply. You will “need to bleed Red.”
  • Ethical, insightful and diplomatic. Serving as the EIC of the Red Journal amounts to leading and shaping our specialty’s premier record of published research. As such, emotions surrounding the journal’s decisions can run high. The successful EIC must have a keen moral compass, be able to carefully manage conflicts of interest and scientific misbehavior and have the diplomatic skills to swiftly and gracefully handle difficult situations. The intellectual safety of the journal and of ASTRO and the scientific community can depend on it. A thick skin is essential — remember, most of the papers that come to the journal are rejected!
  • An excellent writer. It is very important to be able to write well and to write quickly. Editorials, issue highlights, podcasts and similar communications need to be composed with tight turnaround times. Publishing this journal is a rapid endeavor, and being comfortable with writing quickly and decisively will help the process run smoothly.
  • Well-connected. Do you have a diverse web of contacts who can be called upon to act as resources? Networks of connections within radiation oncology and beyond (broader oncology, policy and even politics) will be tremendously helpful. Authors of opinion pieces and editorials, or tie-breaker reviews for tricky papers, are often needed in haste.
  • Visionary. As the EIC, you will be responsible for the entirety of the journal, its content and its editorial board. How will you make the journal your own? What new, innovative ideas would you like to enact? What should the journal look like in five years, and why? Scientific publishing has changed a great deal in the last 10 years and will undoubtedly continue to evolve. The incoming EIC should understand the threats and opportunities presented by this time of great change.

For the right candidate, this will be the most rewarding experience of their professional career. It was an incredible honor for me to be chosen to lead the Red Journal after Dr. Jim Cox and an even greater honor to see it fortify its position as the premier forum for science and ideas in our specialty. I have thoroughly enjoyed the opportunity, and when I pass the baton next year, I would love to do so into an equally proud set of hands. For those of you interested, view the job posting and details on how to apply at www.astro.org/RedJournalEIC.

Posted: May 5, 2020 | 0 comments

Recent Advances article highlights ways to heighten the quality of care and reduce disparities among deaf cancer patients

By ASTRO Journals Team

This month celebrates Deaf History Month, a commemorative time to celebrate deaf history as well as contributions made by the deaf community to American culture and society. We recently sat down with Colin Hill, MD, to discuss his recent publication, “Assessing and providing culturally competent care in radiation oncology for deaf cancer patients,” in the ASTRO Journal Advances in Radiation Oncology. Dr. Hill is one of a few deaf physicians in the United States and is currently completing his residency in radiation oncology at Johns Hopkins. He is a third-generation deaf member of his family and identifies as culturally Deaf, capitalized to reflect that he identifies with the culture and that deafness is not merely a disability.

As Dr. Hill explains in his paper, among people with hearing loss in the United States, there is a distinct linguistic and cultural minority of patients who identify as culturally Deaf and use American Sign Language (ASL), but these patients have not been well studied. Dr. Hill and the research team set out to better understand the needs and challenges deaf patients experience when receiving oncological treatment and performed a review of the literature using the PubMed database to descriptively characterize any existing treatment disparities in this population. Dr. Hill and his team used systematic analysis to identify three universal barriers to care:

  1. Poor health literacy among deaf adults.
  2. Accessibility to tailored health care resources for cancer-specific information.
  3. Poor linguistic and cultural competency among physicians, as physicians and other providers are limited by the lack of educational opportunities or practice guidelines that address how to provide culturally and linguistic sensitive oncological care.

To learn more, we reached out to Dr. Hill to answer a few questions.

Looking at the bigger picture, how could your findings impact patient care? What do you see as the key practice-changing implications of the research?

Colin Hill, MD (CH): We hope this is practice changing by, first, promoting awareness among medical providers about this patient population, emphasizing that they have unique linguistic and cultural needs that have been poorly addressed to date. Second, we hope to eventually promote change on a specialty and national level by developing a standardized care model to guide radiation oncologists and other providers in how to create total communication accessibility within a culturally sensitive framework when treating deaf patients.

Did anything about your findings surprise you?

CH: Shockingly, in a focus group interview, a deaf woman with breast cancer admitted, when asked, she still did not know what cancer was despite being a survivor! It is tragic that such reports of communication failures still exist. Even if a patient is limited by poor health literacy, we need to make every effort to ensure that we create the kind of communication accessibly to prevent such things from happening with our own patients.

How can organizations such as the NAD improve access for deaf patients?

CH: The National Association of the Deaf (NAD) has worked to improve care for deaf patients by improving accessibility for interpreting services, mental health, and creating legal precedents to set standards of care. However, their voice remains small and has not been heard by many in the medical community. The question, in my mind, should rather be what can we do to help organizations like the NAD continue to advance health care for deaf patients and magnify their voice to even further corners of the medical community. Specialty societies should be at the forefront of this conversation. For example, my co-authors, Drs. Curtiland Deville and Brandi Page, are members of ASTRO’s Committee on Health Equity, Diversity and Inclusion (CHEDI), which is poised to lead and collaborate on such initiatives given their mission to advance the status of minorities and the underserved in oncology through educational and professional opportunities, advocacy and awareness.

Should language services for deaf patients be a standard of care for deaf patients?

CH: The Americans with Disabilities Act (ADA) states health care systems and providers are required to ensure effective communication with patients through reasonable accommodations, but this wording is very ambiguous since it remains unclear what that actually means. Several articles highlighted the fact that many physicians often resort to inadequate modes of communication with their patients, such as lip-reading to communicate. Moreover, if interpreting services are provided, the quality of interpretation can be very variable, and it is difficult for providers without any ASL fluency to assess the quality of interpretation. In our opinion, communication accessibility should be viewed as a right. As providers, we need to ensure we understand what communication accessibility actually means for a deaf patient, and how we can create that.

How do you propose we reach patients that have low health literacy?

CH: This is a challenging question, and the reason for the literacy level of a patient is often complex and multifactorial. However, a study showed that even in deaf patients with post-secondary education the literacy levels were lower than expected. This raises the question on how much of this is due to the lack of accessible health care resources for information. For example, many informational videos online often lack captions and would not be accessible to the deaf patient [RTanswers.org proudly provides closed captions for all patient videos]. Creating resources that are inclusive of deaf patients may be one solution.

In your study, you mention that a couple medical schools have implemented programs. What is the role of the residency programs, medical schools and the ACGME? What would be your recommendations for short term actions that could be implemented quickly to help bridge the gap?

CH: Recognizing that culturally Deaf patients are also an underrepresented minority, rather than just a group of patients with a disability, may help spearhead efforts to recruit and train practitioners dedicated to serving this population. The creation of specialized training tracks in areas with a large deaf population could provide opportunities for further training. Promoting the development of educational initiatives that foster linguistic and cultural competency for deaf patients or similar groups could become a goal for the ACGME. Fortunately, our residency program recently presented a related topic at ASTRO, entitled “Establishing an American Sign Language (ASL) Inclusive Residency Training Program” as a starting guide for other residency programs that may be interested in creating inclusive programs.

What would you recommend for a health care practitioner reading this study as the next steps they can personally take to provide care for their deaf patients?

CH: We encourage practitioners to work on creating the ability to provide for ASL interpretation for all clinical encounters. When possible, in-person interpreting encounters should be favored over video remote interpretation. For those located in an area with close proximity to a large deaf community, directly engaging the community for advice on how to improve the quality of interpretation and general guidelines about accessibility may be very beneficial. Furthermore, hospitals often have a Patient and Family Advisory Council (PFAC) that can help provide such community advice for a hospital.

What are your next steps? Will you be pursuing further study?

CH: We are currently working on performing retrospective analysis to characterize the treatment outcomes for deaf patients with cancer compared to the general population. We also hope to eventually develop guidelines that help providers provide linguistic and culturally sensitive care to deaf patients.

More on commemorating Deaf History Month: March 13- April 15

Deaf History Month celebrates deaf history and, in particular, contributions made by the deaf community to American culture and society. Deaf History Month recognizes three major events for the deaf community:

  • April 15, 1817, on which established the American School for the Deaf in Hartford, Connecticut, the first permanent school for persons who are deaf in the United States.
  • April 8, 1864, when President Abraham Lincoln signed the charter for Gallaudet University in Washington, DC, the only university in the world designed to accommodate students who are deaf and hard of hearing.
  • March 13, 1988, the date of the Deaf President Now (DPN) protest at Gallaudet University, which led to the appointment of the first ever deaf president of the university.
Posted: April 15, 2020 | 0 comments

Coming Soon to ASTRO Journals: Data Availability Statements in Published Articles

By Lisa Braverman, Journals Managing Editor

The ASTRO portfolio of journals has had a productive year, with Practical Radiation Oncology’s first-ever impact factor (IF) of 2.794 and a soaring 6.203 IF for the Red Journal. The journals saw special sections about payment policy and gender in radiation oncology, along with groundbreaking podcasts covering topics as wide-ranging as end of life care and machine learning. Looking ahead to 2020, there is another innovation on the horizon: the inclusion of data availability statements in published ASTRO journal articles.

The Journals team invites readers to learn about the new data sharing policy, which goes into effect for articles submitted January 1 and later, by reading the recent Advances in Radiation Oncology article. Readers may also wish to complete  the accompanying CME activity.

ASTRO journals are committed to enhancing research transparency through the inclusion of data availability statements in published works. Importantly, data sharing is not required. While there are many benefits to sharing data — including the potential for faster scientific advancement — we understand not all data can or should be shared. Rather, we are requiring a statement about data availability for all scientific articles. Data availability statements are short descriptions included with scientific publications that provide readers with the conditions surrounding access to data underlying the research being reported. These statements will appear alongside funding and disclosure statements.

In order to better understand how other societies have implemented data sharing policies, we spoke with Ken Kornfield, director of Editorial and Publishing at the American Society for Clinical Oncology (ASCO) and Annie Hill, associate publisher, Community Initiatives at the American Psychological Association (APA). Abridged interviews are below.

What is your data sharing policy?

Ken Kornfield, ASCO (KK): We are putting the finishing touches on a new policy which will include a data sharing statement requirement beginning January 1, 2020. Our current guidelines refer to data sets relevant to the development of predictive or prognostic markers, as well as those relevant to risk assessment. For such data, JCO requires that it be submitted along with the original work as a supplemental file. Whether submitted as a supplemental file, table or figure, the data must be anonymized so as to protect the identities of subjects involved in the research. The same requirement applies to all text, tables and figures submitted as part of the manuscript itself. These data will be published as supporting supplemental material if the manuscript is accepted for publication.

Prior to publication, data sets or sequences relevant to the research must be provided in full, including gene expression profiling data with clinical correlative information. Such data must be anonymized and may be provided either as a supplementary file or by depositing the data in a public database such as GenBank, Gene Expression Omnibus or Array Express, with the accession number provided in the text of the final manuscript. As a condition of publication, it is expected that authors will share all data relevant to the manuscript with readers who may wish to replicate the results.

Annie Hill, APA (AH): APA Journals is committed to openness and transparency and encourages authors to share data when possible (recognizing that it may not always be possible per confidentiality agreements or funder requirements). APA’s Ethics Code does require authors to share data with other professionals for reanalysis after publication (as long as participant confidentiality is protected and the data are not proprietary). Several APA-published journals offer open-science badges to authors who make their data and materials open, and some now require authors to provide data availability statements (indicating whether they will or will not make their data available, along with links to them or explanations as to why they are not available).

When did you implement your policy, and why?

KK: This policy has been in place for at least four years. The reason we did this was for biomarker studies; we wanted others to have access to the data behind the study.

AH: We entered a partnership with the Center for Open Science to offer open science badges to authors and create an APA data repository to ease sharing in 2017. We are also committed to providing resources for authors who are able to share data or materials – making data available can help with replication and facilitate collaboration among researchers, so it’s really a benefit to the field to make it easier to do. Some editors are now requiring data availability statements to further encourage sharing and to get researchers thinking about how to make data available as they plan their studies.

Has anything surprised you about your society’s data sharing policy implementation? If so, what?

KK: We haven’t had any surprises or complaints.

AH: We knew early on that building understanding and consensus would be key, especially for a society publisher with different constituents. What we didn’t anticipate was the depth of knowledge and experience so many constituents would provide! We have a real opportunity to collect this knowledge for the benefit of researchers at every stage of their careers.

ASTRO is committed to research integrity and transparency. Our goals in requiring data availability statements are to facilitate quick identification of relevant data in a study, to promote transparency in instances of access or restriction, and to increase awareness of data availability statement structures. We welcome questions and comments about data availability statements in the comments below or email journals@astro.org.

Posted: December 18, 2019 | 0 comments