e23154 Background: Recent surges in wildfire activity due to climate change pose significant threats to the delivery of consistent oncological care. Assessing the impact of such environmental disasters on the continuity of radiotherapy treatments is essential to mitigate healthcare disruptions and informing policy. Our study investigates the association between California wildfires from 2017-2021 and the adherence to scheduled radiotherapy sessions in cancer patients across multiple clinics, highlighting the interplay between environmental catastrophes and cancer care outcomes. Methods: We retrospectively analyzed 539,292 visits across eight clinics, including Providence Northern California (Petaluma), Providence at St. Joseph Hospital (Eureka), UCSF, and Stanford, extracting data on completed and missed radiotherapy sessions from their Oncology Health Information systems. In conjunction with CAL FIRE wildfire data, we performed univariable and multivariable logistic regression analyses with robust standard errors, adjusting for seasonal variations, clinic-specific effects, and temporal trends. Covariates in the multivariable model included seasonal effects modeled as sine/cosine functions, a linear date to capture time trends, and fixed effects for each clinic. All analyses were conducted using Stata 18.0 and R 4.2.3. Results: Univariable analysis indicated a slight increase in missed appointments when a wildfire occurred within 50km (OR = 1.06 [1.00, 1.11], p = 0.039). Specifically, the missed visit rate was 4.8% without a fire and 5.1% with a fire. Multivariable analysis, controlling for seasonality, temporal trends, and clinic-specific factors, revealed a stronger association (OR = 1.07 [1.02, 1.13], p = 0.007) with adjusted missed rates of 4.8% and 5.2%, respectively. The overall missed visit rate was 4.9%, with 8.8% of visits coinciding with active wildfires within 50 km of a clinic. Conclusions: This initial investigation suggests a potential trend towards higher non-adherence to radiotherapy sessions in the context of wildfire events. While our findings indicate a statistically significant association, they should be regarded as hypothesis-generating. There is a clear imperative for more comprehensive research to delineate which clinics, patient demographics, and disease sites are most susceptible to the deleterious effects of wildfires. Future studies should aim to incorporate a broader array of variables, including physical, psychological, and socioeconomic factors that may confer increased vulnerability to climate-related disruptions. This nuanced understanding is critical to inform targeted strategies that bolster the resilience of healthcare delivery systems and protect cancer patients from the escalating risks posed by climate change.