Software Tools and Simulation Exercises for Radiation Oncology Cyber-Attack Resiliency

This review summarizes the rationale for radiation oncology cyberattack simulation exercises, recent results from multi-institutional resiliency drills, and the landscape of software tools developed to help clinics resume radiotherapy treatments rapidly and safely during a cyberattack or other major clinical software outage. Simulation exercises using record-and-verify (R&V) downtime and File Mode treatment delivery have identified failure modes not apparent in theoretical planning alone, including risks related to treatment documentation, repeated fractions, patient setup, and missed safety checks. Available software tools emphasize insulated backup of DICOM-format planning data and clinical notes, treatment-state dashboards, File Mode treatments, redundant R&V installations, and human-readable treatment records. Future work should emphasize minimization of backup latency, ensuring File Mode feasibility under a variety of outage conditions, facilitation of inter-institutional patient transfer, and postattack data reconciliation.