Building Resilient Radiotherapy Systems: Lessons and Recommendations for Natural Disaster Risk Mitigation.

Natural disasters, including earthquakes, hurricanes, floods, wildfires, and severe winter storms, along with related technological failures such as prolonged power outages or even nuclear incidents, pose significant risks to radiotherapy continuity, where treatment interruptions are associated with compromised tumor control and survival outcomes. Since natural disasters are inevitable, building resilient radiotherapy systems requires systematic learning from prior disasters and proactive risk management. In this narrative review, we synthesized published literature, incident reports, and operational guidance to identify common vulnerabilities observed from past environmental emergencies, clinical consequences of interruptions, and effective mitigation practices. Across disaster types, radiotherapy services are commonly disrupted by power and utility failures, facility damage, staff shortages, and limited patient access to the facility, resulting in delayed or missed treatments with potential negative oncologic effects. Drawing on these lessons, we outline mitigation strategies across 8 key domains: emergency governance and preparedness; facility and infrastructure resilience; power, utilities, and technical continuity; data, IT and communication systems; clinical care continuity; treatment interruption mitigation; workforce safety and continuity; and patient navigation and support. These recommendations support the development of resilient radiotherapy systems to address short- and long-term treatment interruptions caused by natural disasters.