In the more than 7 months since Russia invaded Ukraine on February 24, 2022, cancer care for Ukrainian citizens has changed dramatically. Ukraine was once a country able to provide its approximately 160,000 newly diagnosed patients with cancer each year with modern diagnostic methods, including tissue biopsies, molecular genetics, and imaging scans, and access to common treatment modalities, such as surgery, systemic treatments, radiotherapy, and hematopoietic stem cell transplantation. Today, much of this care has been substantially diminished (if it exists at all) in some cities.
“We are currently performing about 30 surgical procedures a day, which is about 50% of our usual surgical capacity before the war.”— Andriy Hrynkiv, MD
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According to Ukraine’s health ministry, as of July 28, 2022, 18 medical workers have been killed and more than 50 have been injured since the start of the war; 746 medical facilities have been damaged, and an additional 123 facilities have been completely destroyed.1 Damages from bombings to critical civilian infrastructures, including power plants, transportation hubs, and medical supply chains, are further impeding access to even basic health care in the country.
Cancer is the second leading cause of death behind cardiovascular disease in Ukraine. Research shows that at the start of the war, an estimated 139,000 Ukrainians were living with newly diagnosed cancer, and between 1,000 and 1,200 children were receiving active cancer treatment.2
The United Nations High Commissioner for Refugees (UNHCR) has declared Ukraine a level 3 humanitarian emergency—the highest level the agency confers on a crisis. In addition, a report by UNHCR shows that at the end of August, approximately 13 million Ukrainians had been uprooted from their homes since the start of the war; more than 6.3 million have fled to neighboring countries, and 6.6 million are believed to be displaced within Ukraine.3
Establishing Resource Centers
Just days after Russia’s invasion of Ukraine, ASCO, in partnership with the American Cancer Society (ACS) and the Sidney Kimmel Cancer Center–Jefferson Health, began assembling resources to establish a network of oncology professionals to help Ukrainian patients with cancer find clinical care, either in Ukraine or in a host country, and to help support providers receiving these patients with questions about care. Soon after, ASCO, along with the World Health Organization (WHO), the European Union Commission, the newly formed ASCO–European Cancer Organisation (ECO) Ukraine Steering Committee, and the ECO Board launched a Special Network (www.europeancancer.org/topic-networks/20:impact-war-in-ukraine-on-cancer.html) to establish a centralized resource center for Ukrainian patients with cancer and for refugees fleeing to bordering countries, to help them continue receiving cancer care. The Special Network now includes representatives from more than 300 organizations.
A month after the war started, ASCO and ECO held a media briefing on the state of the refugee situation with reports from oncologists in Ukraine (including Andriy Hrynkiv, MD, a surgical oncologist at Lviv Regional Cancer Center of Ukraine and Ukraine Member, ASCO Central and Eastern European Regional Council), Poland, and Romania (https://meetings.asco.org/asco-international-events/14629?presentation=206234#206234). During his presentation, Dr. Hrynkiv described both the human and material toll the Russian invasion is having on the people of Ukraine, including the disruption in oncology care for patients with cancer.
“In the city of Kyiv, with a population of 3 million citizens, oncology centers are just providing emergency care and outpatient chemotherapy. Doctors in what is now the epicenter of military actions are facing extreme psychological pressure and even threats to their lives,” said Dr. Hrynkiv.
On August 25—the day after the country marked its 31st anniversary of independence from Soviet rule—The ASCO Post talked with Dr. Hrynkiv to receive an update on the crisis in Ukraine. On that day, Russian forces increased air and missile strikes on civilian targets across the country, including a railway station in Chaplyne, about 74 miles from the southeastern Ukrainian city of Dnipro, killing at least 22 people and wounding 50 others. A few days later, Russian shelling intensified near a nuclear power plant in the city of Zaporizhzhia. Here is an edited version of that conversation.
Assessing Cancer Care for Patients
At the 6-month mark since the Russian invasion of Ukraine, the war is escalating. Are you and your colleagues safe in Lviv?
We are safe. But yesterday was Ukrainian Independence Day, and during the day we heard seven air raid alarms throughout the city. As we were working in the chemotherapy department in the Lviv Regional Cancer Center of Ukraine, we needed to stop chemotherapy infusions and take our patients back and forth to the shelter seven times. It took about 7 to 8 hours to give all of our patients chemotherapy; some of them were not able to get home and had to stay at the hospital to rest.
What is the current situation for patients with cancer in Ukraine? How are you able to care for patients, and do you have enough cancer treatments and diagnostic equipment at your hospital?
Yesterday, due to Ukrainian Independence Day, we were expecting several provocations from Russian forces. This is why we emptied most of our surgical beds during the day, and we weren’t allowed to perform certain scheduled surgical treatments on patients with cancer. We are currently performing about 30 surgical procedures a day, which is about 50% of our usual surgical capacity before the war.
We have some patients who need radiation therapy at our cancer center, because it is the biggest center in the Western part of Ukraine. The problem is that we have one fairly new linear accelerator and one that is relatively old—so we don’t have enough cobalt machines, and our old machine needs repairs. We are able to perform between 160 and 180 radiation therapies per day, and among these patients, about 15% are displaced from their homes. So, the situation is better, and the number of patients coming from other parts of the country has decreased.
Regarding chemotherapy, we try to share our patients with different hospitals because we do not want to create large crowds of people within our hospital. Providing chemotherapy to patients is much easier than providing radiation therapy because we do not have enough radiotherapy equipment or personnel to administer the therapy. With chemotherapy, we can prescribe medication and send the patient to another hospital to administer the treatment.
Providing Care for Refugees
Please talk about the efforts of the ASCO-ECO Special Network. Is progress being made in having more patients treated, and are there enough oncologiststo care for patients in Ukraine and host countries?
I would like to express my gratitude to ASCO, ECO, and the other cancer organizations for the constant support they have provided us, because their efforts are really helping to provide cancer care for patients both in Ukraine and in neighboring countries. I have talked with physicians in Poland who are treating Ukrainian patients, and we are very grateful they are helping with our patients. All these efforts are organized so brilliantly—for example, our patients are receiving information materials printed in the Ukrainian language when they cross the border, so they know how to find hospitals to continue their cancer treatment.
Procuring Enough Medication
As the war continues, how are you able to restock cancer medicines and maintain an oncology staff in Ukraine?
We do have an issue with not having enough cancer medicines, because our hospital is pretty big and we provide treatment for a lot of patients needing chemotherapy every day. On some occasions, we require our patients to buy medications. For example, I have a patient who needs adjuvant carboplatin, and he needs to buy the drug, but hopefully the medication is not too expensive and he will be able to afford it.
We are receiving some financial aid from abroad to procure and provide cancer therapies, for which we are also very grateful. Most of the aid goes to Kyiv and is then divided among hospitals throughout the country, so the process takes some time and is a bit cumbersome. Drug shortages are a big problem, and we need to speed up this process.
Seeing Signs of Hope
Do you have any statistics on how many patients with cancer have left Ukraine and are being treated in other countries? How are patients being tracked at the border for their treatment needs, and is there a cancer registry being kept at the border?
It is very difficult to answer these questions because our national cancer registry is not working correctly under such difficult -circumstances, so it is very difficult to process accurate information. We are getting some information from Poland and other neighboring countries, but I don’t know exactly the number of patients coming back and forth across the border.
However, the general situation of the number of border crossings is improving. For example, I saw a recent statistic showing the number of Ukrainians crossing the border to Poland is 5.6 million, and 8.6 million Ukrainians have crossed the border from Poland to Ukraine. So, conditions are improving in Ukraine because even though 7 million people have fled the country, a large number of these people are returning to their families.
In our hospital, we are starting to see some patients who received cancer treatment abroad and are now coming back here. We are delighted to see this.
The website onco-help.org provides resource materials for patients with cancer in Ukraine, Poland, Romania, Moldova, and Hungary, with translation to the Ukrainian language. It’s a very helpful site, because it provides Ukrainian patients with information on different health-care facilities within Ukraine and across Eastern Europe.
Streamlining the Drug Procurement System
What are your immediate needs to provide care for your patients with cancer?
Our immediate need is to have a less cumbersome system to procure cancer treatment for patients. It is very hard to get supplies of even common chemotherapy drugs such as carboplatin, which is an inexpensive drug but is very difficult to procure and can take months to receive from Kyiv. We need a more flexible procurement and medication sharing system.
As I mentioned, another issue we have is with our radiation therapy equipment. One current unit is quite old, and we are treating many more patients than we were before the war—more than the machine was built to treat. We also have a problem with shortages of supplemental material for surgery, such as surgical stoppers. Streamlining the procurement system would alleviate some of these issues.
DISCLOSURE: Dr. Hrynkiv reported no conflicts of interest.
REFERENCES
1. Matthews AL, Stiles M, Nagorski T, et al: The Ukraine War in data: 869 attacks on healthcare facilities. Grid, July 28, 2022. Available at www.grid.news/story/global/2022/07/28/the-ukraine-war-in-data-869-attacks-on-healthcare-facilities. Accessed September 15, 2022.
2. Kizub D, Melnitchouk N, Beznosenko A, et al: Resilience and perseverance under siege: Providing cancer care during the invasion of Ukraine. Lancet Oncol 23:579-583, 2022.
3. USA for UNHCR, The UN Refugee Agency: Ukraine emergency. Available at https://www.unrefugees.org/emergencies/ukraine. Accessed September 15, 2022.
