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As Hurricane Helene approached western North Carolina, Martin Palmeri, MD, MBA, didn’t anticipate the storm would disrupt practice operations for more than a day or so.

But the massive rainfall and flooding damage last September proved to be far more challenging. Despite best efforts by the 13-physician practice, basic treatments for most patients were interrupted for about a week.

Flooding washed out some of the major roads leading to the main Asheville clinic and affiliated rural sites, limiting travel and slowing delivery of medications, intravenous (IV) fluids, and other supplies, Palmeri said. Some patients and employees weren’t initially reachable due to the loss of the internet and cell phone service. The storm-related fallout even forced patients to relocate elsewhere for weeks or longer.

During the storm, backup generators kept power on at the Asheville clinic, protecting chemotherapy and other refrigerated drugs, but the storm damaged the municipal water supply.

“Water was the number one thing — how do you get water to the office?” Palmeri said. “You can’t give someone an 8-hour infusion if they don’t have means of going to the toilet or having something to drink.”

Hurricanes. Wildfires. Heat waves. As climate-driven extreme weather has become more common, researchers, oncologists, and patients are increasingly being forced to consider the consequences of these disruptions.

Along with preventing patients and providers from reaching treatment sites, experts said, extreme weather can undercut patients’ health and care in other ways. Patients with more limited lung capacity following lung cancer surgery, for instance, may struggle with breathing during wildfires. Extreme heat can prove risky for patients already dehydrated or weakened by treatment-related side effects. Power outages and severe flooding can affect vital infrastructure, disrupting operations at facilities that manufacture essential drugs. Power outages can also impede radiotherapy, which requires machines powered by electricity.

“Any of these [weather] events can disrupt this critical cancer care continuum among a population of people that already are very vulnerable,” said Joan Casey, PhD, an environmental epidemiologist and associate professor at the University of Washington in Seattle.

Extreme Weather and Cancer Survival

For patients with cancer, survival often relies on highly regimented protocols, which may require surgery plus frequent visits for radiation, chemotherapy, or immunotherapy that can last months, said Eric Bernicker, MD, a Colorado oncologist and lead author of a 2023 American Society of Clinical Oncology position statement about the impact of climate change on cancer care.

Interruptions to care, regardless of the cause, can lead to worse outcomes for patients, Bernicker said. “If you’re in the middle of your post-lumpectomy radiation and your radiation center shuts for 2 weeks,” he said, “that is not good.”

Research indicated that even short treatment disruptions can affect outcomes for patients with cancer and that delays caused by extreme weather — which may last for weeks — can affect survival for these patients.

One analysis, published in JAMA Oncology in 2023, found that patients exposed to wildfire within the first year after potentially curative lung cancer surgery had worse survival outcomes than those who weren’t exposed during their recovery.

In another study, patients with lung cancer who had their radiation interrupted when a hurricane struck had a 19% greater risk of dying overall compared with similar patients who were not affected. Another analysis found that patients with breast cancer who were partway through treatment when Hurricane Katrina hit the Louisiana coastline had a significantly greater risk of dying over a 10-year period compared with patients who lived elsewhere.

The potential threats to survival highlighted the impacts of extreme weather on carefully orchestrated systems of care that place patients facing already fragile situations in impossible binds, Casey said.

Douglas Flora, MD, a Kentucky oncologist and president-elect of the Association of Cancer Care Centers, Rockville, Maryland, agreed.

“We’ve seen this with an increasing frequency over the last several years,” Flora said. “It’s one thing if it’s routine follow-up or surveillance care, but many cancer patients’ survivals are directly related to not having interruptions in their care.”

Challenging Realities

Following Helene, the most pressing issue was the lack of water, Palmeri said.

The lack of reliable clean water created challenges for patients receiving radiation or chemotherapy infusions, which can cause vomiting and diarrhea that leave patients dehydrated. Toilets were also unusable.

Even when the city of Asheville said the water was likely safe enough to bathe in, local leaders still reported potential risks from bacteria and other contaminants in the water, Palmeri said. Those with a fragile immune system or breaks in the skin “could get serious and life-threatening infections,” he explained.

To make matters worse, damage to a North Carolina facility manufacturing IV fluids left the United States in shortage for months. IV fluids are key not only for providing hydration but also for easing nausea, fatigue, and other issues caused by cancer therapies.

With wildfires, as occurred in southern California early this year, patients undergoing cancer treatment might feel they have no option but to remain near home to continue getting care, Casey said. “It’s restricting their agency in the kinds of choices that they have to make during these severe weather events.”

Meanwhile, thick wildfire smoke can confine patients to their homes, said Lawrence Wagman, MD, a surgical oncologist and a regional medical director at the City of Hope network, who described its main facility in Duarte, California, coming within a dozen miles of the Eaton fire. “One of the biggest problems was so much smoke in the air,” he said. “And the air quality was so low that it was, in many ways, dangerous for patients to travel.”

“These fires were so aggressive, and they kept popping up,” Wagman said. Plus, the emotional strain of looming wildfires persisted for both patients and cancer clinicians for weeks on end, he added.

For those who evacuate, the logistics can be complex.

Not only are cancer treatment plans highly structured, but switching care to another facility is far from easy, Bernicker said. The new facility will likely need to submit a treatment plan and get insurance coverage before moving forward.

“I’m not saying that takes forever,” he said. “But what I’m saying is that it’s not like you just roll in and they hang the [infusion] bag.”

Neither is a shelter typically an option for patients during treatment, said Seth Berkowitz, a licensed clinical social worker and director of Strategic Healthcare Partnerships at The Leukemia & Lymphoma Society. “They have to have a place to go that’s safe and germ-free.”

In western North Carolina, the strain on already ill patients and their caregivers could be overwhelming, Palmeri said. He recounted how the husband of one patient with advanced cancer died after the storm came through.

“He tried to go out there with a chainsaw to clear a way out so that they could get out of their house in case he needed to take her to the hospital,” Palmeri said. “And he had a heart attack there in the driveway.”

Rebuilding and Planning Ahead

Experts are only at the early stages of grasping the magnitude of extreme weather on cancer care and developing strategies to curtail care gaps and potential harm to patients, said Katie Lichter, MD, a radiation oncologist at the University of California San Francisco, who studies extreme weather and cancer treatment.

“How does it impact health care delivery services at every step, from prevention to screening to treatment and survivorship?” Lichter asked. “We’re just starting to understand and to even quantify that,” she said, which included identifying patients who are most vulnerable. She worries, in particular, about patients living in rural areas who already travel longer distances and often face more difficulties accessing care.

The gap between research and reality still looms large. A recent analysis, led by Lichter, looked at 176 California radiation oncology clinics and found that all of them were located within 25 miles of a wildfire that had occurred within the prior 5 years. Yet among the 51 clinics that responded to a 2022 survey,just 47% reported that their clinic had a wildfire emergency preparedness plan.

The American Cancer Society does provide some guidance on how patients can prepare for a weather-related crisis, including having extra supplies of medications or special equipment on hand.

Still, providers are often in reaction mode when extreme weather strikes.

Without adequate clean water after Helene, leaders at Palmeri’s practice moved swiftly, purchasing 40,000-50,000 bottles of water and bringing in porta potties from elsewhere. 

“I think we were able to get things up and going very quickly,” said Palmeri, who noted that full services resumed about 10 days after the storm. “For most patients, missing a week of treatment would not do a disservice to their well-being or outcome.”

Going forward, to provide a more comprehensive strategy, Lichter is working with colleagues to develop clinical tool kits to help oncology practices and patients prepare for severe weather events, such as outlining backup treatment contingency plans, ensuring early medication refills, and boosting communication with patient alert systems.

Clinicians are also implementing their own strategies. To limit communication gaps during power outages, Palmeri said that, since Helene, his practice has made sure that their clinic sites, physicians, and other key people now have cell phone service through satellite via Starlink.

“No one has phone books anymore,” he said, so cancer clinicians should keep crucial contact information on paper, such as details about businesses that distribute water and porta potties, given that online searches may not be feasible.

Clinicians should also advise patients to keep a hard copy of recent medical findings handy, including medications and lab results, in case they arrive at an emergency room far from home and physicians can’t access their electronic health record, Bernicker said.

When there is enough advance warning of an approaching weather event, clinicians can help patients keep at least a week’s worth of medication on hand for symptom-related issues, such as nausea or pain, as well as antibiotics so patients don’t have to seek out emergency care during the crisis, Bernicker said. However, Bernicker noted, some insurers may be reluctant to fill certain prescriptions in advance, like those for opioids.

Making headway on more robust preparedness strategies may be slowed. As of March, the National Institutes of Health will no longer fund research about the health effects of climate change.

Bernicker hoped that such cutbacks would be rolled back. What’s on the line, he stressed, is maintaining the highest quality of care for patients with cancer.

“We really are in a golden age of oncology therapeutics,” he said. “We have patients living longer than anyone would have predicted 20 or 25 years ago. But all those advances are contingent on people having access to their centers and not having that interrupted.”