Dealing with digital paralysis: Surviving a cyberattack in a National Cancer center

INTRODUCTION

Cyberattacks represent a growing threat for healthcare delivery globally. We assess the impact and implications of a cyberattack on a cancer center in Ireland.

METHODS

On May 14th 2021 (day 0) Cork University Hospital (CUH) Cancer Center was involved in the first national healthcare ransomware attack in Ireland. Contingency plans were only present in laboratory services who had previously experienced information technology (IT) failures. No hospital cyberattack emergency plan was in place. Departmental logs of activity for 120 days after the attack were reviewed and compared with historical activity records. Daily sample deficits (routine daily number of samples analyzed - number of samples analyzed during cyberattack) were calculated. Categorical variables are reported as median and range. Qualitative data were collected via reflective essays and interviews with key stakeholders from affected departments in CUH.

RESULTS

On day 0, all IT systems were shut down. Radiotherapy (RT) treatment and cancer surgeries stopped, outpatient activity fell by 50%. hematology, biochemistry and radiology capacity fell by 90% (daily sample deficit (DSD) 2700 samples), 75% (DSD 2250 samples), and 90% (100% mammography/PET scan) respectively. Histopathology reporting times doubled (7 to 15 days). Radiotherapy (RT) was interrupted for 113 patients in CUH. The median treatment gap duration was six days for category 1 patients and 10 for the remaining patients. Partner organizations paused all IT links with CUH. Outsourcing of radiology and radiotherapy commenced, alternative communication networks and national conference calls in RT and Clinical Trials were established. By day 28 Email communication was restored. By day 210 reporting and data storage backlogs were cleared and over 2000 computers were checked/replaced.

CONCLUSION

Cyberattacks have rapid, profound and protracted impacts. While laboratory and diagnostic deficits were readily quantified, the impact of disrupted/delayed care on patient outcomes is less readily quantifiable. Cyberawareness and cyberattack plans need to be embedded in healthcare.

POLICY SUMMARY

Cyberattacks pose significant challenges for healthcare systems, impacting patient care, clinical outcomes, and staff wellbeing. This study provides a comprehensive review of the impact of the Conti ransomware attack on cancer services in Cork University Hospital (CUH), the first cyberattack on a national health service. Our study highlights the widespread disruption caused by a cyberattack including shutdown of information technology (IT) services, marked reduction in outpatient activity, temporary cessation of essential services such as radiation therapy. We provide a framework for other institutions for mitigating the impact of a cyberattack, underscoring the need for a cyberpreparedness plan similar to those made for natural disasters and the profound legacy of a cyberattack on patient care.

Tolerability and toxicity profile of chemotherapy with oxaliplatin in combination with infusional fluorouracil (FOLFOX) and capecitabine (XELOX) in a community oncology setting

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Background: Chemotherapy regimens combining oxaliplatin with infusional fluorouracil (folfox) and capecitabine (xelox) have been found to be superior to fluoropyrimidine chemotherapy alone in colon cancer and are also useful in other gastrointestinal tumor types, including gastro-oesophageal cancers. We retrospectively assessed the tolerability and deliverability of the folfox and xelox regimens in a community oncology setting. Methods: Patients (pts) receiving folfox or xelox chemotherapy for gastrointestinal malignancies over a five year period from 2006 to 2011 were identified through a pharmacy database. Patient and tumour characteristics were recorded. For each regimen, delays in planned chemotherapy administration (>3 days) as well as dose reductions were recorded. Reasons for dose modification and/or treatment discontinuation were recorded. Regimens were compared for these outcomes using Fisher's exact test for categorical variables and unpaired t-test for continuous variables. Results: Of 138 pts with adequate information for assessment, 94 received folfox and 44 received xelox. Pts who received folfox were more likely to experience dose delays (64% vs. 36%, 2-sided p=0.003). The mean dose delays during folfox and xelox were not significantly different (12.2 vs. 10.8 days, t-test p=0.657). Pts who received folfox were less likely to require any dose reductions during therapy (31% vs. 50%, 2-sided P=0.038). Similar numbers of pts receiving folfox and xelox required dose reductions of oxaliplatin (27% vs. 32%, 2-sided p=0.548), while fewer pts receiving folfox required dose reductions of the fluoropyrimidine component (14% vs. 39%, 2-sided p=0.002). Conclusions: We found that more pts required dose delays during treatment with infusional fluorouracil-based versus capecitabine-based oxaliplatin regimens. However, the infusional regimen was associated with considerably less dose reductions, largely related to the fluoropyrimidine component. We favour infusional fluoropyrimidine-based chemotherapy unless other factors (e.g., distance to the oncology unit) support oral fluoropyrimidine use.