Strengthening Resilience and Adaptive Capacity to Disasters in Cancer Control Plans: Lessons Learned from Puerto Rico

Extreme weather and disasters such as hurricanes are immediate ways in which we are experiencing climate variability. Many climate-related extreme events are increasing in intensity, duration, and frequency due to anthropogenic climate change, and there is an increased potential for impacts due to the location of people and critical infrastructures (1). Aside from the direct impact that disasters may bring on the general population, there is a growing concern about their effects on human health, especially among vulnerable populations and with limited adaptive capacities. According to the U.S. Fourth National Climate Assessment (2), “Climate change creates new risks and exacerbates existing vulnerabilities in communities across the United States, presenting growing challenges to human health and safety….” This underscores the need to have plans that are responsive to the potential adverse health consequences of disasters.

A growing body of research shows that disasters lead to major disruptions in health care systems and community infrastructure, impacting health outcomes (3). Patients with cancer are among the most vulnerable populations in the aftermath of a disaster as disruptions of care can negatively affect their cancer outcomes (4, 5). A recent review of the literature showed that damage to infrastructure, communication systems, medication supply, and medical record losses gravely disrupt oncology care in natural disaster situations and highlighted the need to prioritize patients with cancer during disaster planning (6). Therefore, continuation and proper delivery of cancer care is among the top medical management priorities after a disaster (7). According to the United Nations' Sendai Framework for Disaster Reduction: 2015–2030 (8), “People with life-threatening and chronic disease, due to their particular needs, should be included in the design of policies and plans to manage their risks before, during, and after disasters, including having access to life-saving services.”

U.S. mainland coastal areas and island territories are particularly vulnerable to tropical storms, floods, and hurricanes (3). As recent as September 2017, Puerto Rico and the U.S. Virgin Islands were hit by consecutive category 4/5 hurricanes. Hurricanes Irma and Maria caused major disruptions in essential services and environmental health issues. In the case of Puerto Rico, 100% of the population was left without electric service, 70% without potable water, 95% without communications, and over 250,000 houses were destroyed or seriously damaged (9). Many were isolated after bridges and roads collapsed, and most experienced major disruptions in transportation. In addition, most of the health care system became inoperable (10) and 2 years after the disaster, many hospitals and community health centers continue facing critical challenges in infrastructure and the delivery of oncology care (11). Lapses between cancer diagnosis and treatments or interruption of treatment can have a concerning effect on the health outcomes of patients with cancer (12).

In the case of U.S. Virgin Islands, a recent publication documented how Hurricanes Irma and Maria caused massive disruptions to health care in St. Thomas, and highlighted the need for a more resilient health care system in this U.S. territory (13). The impact of these hurricanes on oncology care and health outcomes of patients with cancer in Puerto Rico has yet to be documented and is the focus of ongoing research projects funded by the NIH (NCI 1R21CA239457-01, NCI 1R21CA239456-01, and NIMHD 5R21MD013674-02). The research project led by our team studies how Hurricanes Irma and Maria affected cancer care among patients with gynecologic cancer in Puerto Rico and the U.S. Virgin Islands. Findings from these studies will inform future cancer management plans during and after natural disasters (14). As an example of interest, based on the experience in Puerto Rico, recommendations were published recently by radiation oncologists in the island and from a panel of experts from the American Society for Radiation Oncology, with the intent of helping to alleviate treatment interruptions of patients with cancer in the future (15). Development of an emergency operations plan was a key aspect of the recommendations proposed.

U.S. states and territories, including Puerto Rico, adopt the Federal Emergency Management Agency (FEMA) doctrines and principles, including the National Incident Management System and the National Response Framework, among others. The Puerto Rico Emergency Management Bureau is the lead agency responsible for emergency management in the island, organizing state agencies under the Emergency Support Function (ESF) model developed by FEMA (16). The ESF model is used for organizing the managing resources for U.S. states and territories before, during, and after a critical event, and focuses on essential services required during emergencies and disasters. The Puerto Rico Department of Health is responsible for leading the ESF-8: Public Health and Medical Services function (17). Preparedness, mitigation, response, and recovery matters regarding public health and medical services are executed through federal funding granted to the Puerto Rico Department of Health Office of Public Health Preparedness and Response by the Centers of Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response. Activities involve the development, review, exercise, and update on a regular basis of the ESF-8 Public Health and Medical Services Emergency Operational Plan, to ensure that it can be implemented during an event. This document is based on planning strategies for all hazard scenarios and is supported by several annexes that address specific considerations, including those for Access and Functional Needs Populations. Nonetheless, in Puerto Rico, specific plans for patients with cancer are not yet included within this plan.

The CDC provides funds to all U.S. states, territories, and tribe/tribal organizations to establish region-specific comprehensive cancer control plans (CCCP; ref. 18). These plans address the burden of cancer in each region and promote the use of evidence-based strategies to meet goals and objectives for cancer control. We conducted an ad hoc review of existing CCCPs and found that none included goals or objectives for disaster-specific cancer management. This finding highlights the need to include such goals, objectives, and strategies in CCCPs tailored to the resources, cancer burden, and potential disasters in each community, to support quality cancer management during and after a disaster. There are disaster emergency resources and plans for patients with cancer from different stakeholders (19, 20), but they need to be reviewed, adapted, and incorporated into CCCP's goals and objectives. Currently, CCCPs incorporate policy, systems, and built environment change interventions to support cancer control initiatives; so many disaster plans would align with the structure of cancer plans (21).

Specific emergency response plans for patients with cancer within a disaster situation should be housed within the established EFS (16) plans infrastructure of each jurisdiction, to ensure they are executed during an event. Nonetheless, the CCCP's should guide (i) the efforts for patients with cancer by including goals and objectives within this topic within their plans, and (ii) the science and research review to make recommendations to the ESF coordinators, in terms of what should be included in their plans. As appropriate, elements regarding planning, preparedness, response, and recovery should be included (22) in emergency response plans, and CCCPs goals and objectives should be aligned to these plans, and help strengthen them. Our goal is to promote the integration of such plans to benefit the cancer patient population before, during, and after a disaster situation.

What should be included in CCCPs? On the basis of our own experience in Puerto Rico, we suggest CCCPs consider the following:

• (i) Use data for the planning and evaluation. Each plan must focus on the cancer control continuum (23) and should be based on data from the scientific literature, the community characteristics, and the cancer burden of the community.

• (ii) Etiology and prevention. After a hurricane, both known and unknown cancer risk factors could be aggravated in the population and understanding such factors should be a goal within the cancer control plans. These could include changes in lifestyles (e.g., change in diet given limited access to fresh produce and increased consumption of alcohol or tobacco given augmented stress levels), postponing/interrupting preventive care (e.g., recommended vaccines), and exposure to environmental pollutants, among others (6, 12). Thus, although the main focus of disaster plans is short and intermediate impacts of disasters, some of these risk factors could have long-term effects on the general population, potentially increasing their risk of certain cancers.

• (iii) Screening and early diagnosis. The utilization of screening and diagnostic services might also be delayed or interrupted, or these procedures might become a secondary priority in the aftermath of a disaster. Lack of availability of these services could result in delays in diagnosis and treatment.

• (iv) Treatment and survivorship. The maintenance of cancer medications that need refrigeration could be affected during a disaster and on its aftermath, potentially reducing medications available for the population. Also, environmental stressors, and the disruption of essential services, such as electric power and water, may result in delays in treatment services, such as surgery, chemotherapy, radiotherapy, etc. Given the potential interruption of health care services upon a disaster, the survival of patients with cancer may be affected, and the risk of recurrence can be increased. In addition, social and environmental stressors, as well as oncologic care interruption may affect the quality of life of patients with cancer. Thus, efforts must be made to generate information and infrastructure that guarantees adherence to cancer treatments and symptom management through a natural or man-made disaster. In addition, plans should be made to guarantee preparedness and organized response upon a disaster, to be able to have medication properly maintained and available, continue treatment, and/or reduce the amount of time these services are interrupted for these patients.

The integration of CCCPs goals, objectives, and strategies to local emergency response plans will require multi-agential participation coordinated by local (state-level) health departments. Stakeholders should include Cancer Control Coalitions, Comprehensive Cancer Control Programs, cancer centers, universities, health care professional associations (e.g., radio-oncologists, hematologists-oncologists, and radiation oncologists), organizations that provide services to patients with cancer (e.g., hospitals, pharmacies, insurance companies, and nonprofit organizations such as the American Cancer Society), and federal agencies (Department of Health and Human Services and its Office of the Assistant Secretary for Preparedness and Response and Federal Emergency Management Agency). Equally important, patients with cancer and survivors should be actively involved in such plans, as their experience can be used to better understand what went wrong, what worked, and what can be improved. Not only will key stakeholders will be able to support and assist in the dissemination of such a plan, but this communication and coordination will facilitate that they properly include patients with cancer and their treatments into their disaster-related medical care plans.

In conclusion, research should continue increasing our understanding of the impact of disasters on health outcomes on affected populations and the impact of stressors on cancer health outcomes and cancer survivorship, and quality of life. Specific plans for patients with cancer within a disaster situation should be included within the established EFS infrastructure of each jurisdiction, to ensure that they are executed during an adverse event. In addition, the CCCP's should guide the efforts for patients with cancer by including goals and objectives within this topic within their plans, and by collaborating with local emergency plans for the inclusion of appropriate strategies for patients with cancer. The CCCPs are a valuable resource for plan development as they are present in all states, territories, and tribes, and they provide an infrastructure for the development, implementation, dissemination, evaluation, and periodical revision of these plans. These plans, particularly in isolated geographic areas such as Puerto Rico, should consider the logistics of immediate responses to disasters, given that the response by state and federal agencies and other organizations may be delayed given their geography. According to the National Climate Assessment for the Caribbean Region, “High levels of exposure and sensitivity to risk in the U.S. Caribbean region are compounded by a low level of adaptive capacity, due in part to the high costs of mitigation and adaptation measures relative to the region's gross domestic product” (2). However, we acknowledge climate hazards are not the only threats that can affect quality of life of patients with cancer. Therefore, these plans should also consider even major catastrophic events such as the earthquakes that occurred on the Southwest region of Puerto Rico on January 2020. We expect that these integrated and collaborative plans will have a positive effect on cancer control strategies upon disaster situations in the United States and the Caribbean Territories. In addition, they could guide the development of disaster management plans for other health conditions. These are the type of actions needed to strength resilience and adaptive capacity to climate-related hazards within populations. The coordinated and multi-sectorial involvement of all these groups will guarantee that such a plan is effective.

G. Tortolero-Luna reports receiving other commercial research support from AbbVie. No potential conflicts of interest were disclosed by the other authors.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Research reported in this article was fully supported by the NCI of the NIH under award number R21CA239457, granted to A.P. Ortiz, P. Mendez-Lazaro, W.A. Calo, and G. Tortolero-Luna. In addition, this article is partially supported by the Centers for Disease Control and Prevention under award number NU58DP006318, awarded to G. Tortolero-Luna.