Impact of compounded financial collapse and armed conflict on access to radiation therapy in Lebanon: lessons for building resilient cancer care systems in fragile settings.

BACKGROUND: Lebanon's radiation therapy (RT) system has been exposed to successive, overlapping crises since 2019, including financial collapse, the Beirut Port explosion, and armed conflict in 2024. This study analyzes the impact of compounded crises on RT access and practice patterns using longitudinal institutional data from Mount Lebanon Hospital (MLH) as a sentinel cohort. METHODS: A retrospective observational study was conducted at MLH (2018-2025). Annual treated patient volumes, treatment technique distributions (3D-CRT, IMRT, SBRT, SRS), and hypofractionation adoption patterns were analyzed. Crisis phases were defined as: pre-crisis baseline (2017-2018), acute economic collapse (2019-2020), subacute adaptive phase (2021-2022), and chronic/war-related phase (2023-2025). National RT workforce and infrastructure data were assessed against ESTRO-HERO and IAEA benchmarks. RESULTS: RT patient volume exhibited non-linear evolution: initial increase from 1,186 (2018) to 1,498 (2022), a modest decline to 1,328 (2023), with recovery to 1,399 (2024) and 1,479 (2025) coinciding with war-related patient centralization. A sustained shift occurred from 3D-CRT (>80% in 2018) to IMRT, SBRT, and SRS (>50% by 2025). Hypofractionated breast radiotherapy increased from 34.1% (2023) to 73.0% (2025), with a marked inflection point in 2024. Lebanon's RT workforce falls below ESTRO benchmarks for radiation therapists (3.9 vs. 5-7 per LINAC) and medical physicists (0.8 vs. 1.2-1.7 per LINAC). CONCLUSION: RT systems in fragile settings do not fail linearly but fluctuate under sustained strain, and apparent volume stability at a single resilient center can mask systemic national contraction. Crisis conditions accelerated hypofractionation adoption and technique modernization. We further identify the need for a structured Radiation Therapy System Resilience Score (RT-SRS) and define its candidate domains as a conceptual, hypothesis-generating framework to guide proactive vulnerability detection in fragile settings; its operationalization and validation are designated as future work.