All scheduled cancer care across Ukraine has been stopped as more than 60 hospitals have been badly damaged in the course of Russia’s invasion, Ukrainian oncologists say.
“In the city of Kharkiv, with an approximate population of one and a half million citizens, the one oncological hospital is destroyed, the only hospital in this area,” said Andriy Hrynkiv, a surgical oncologist at the Lviv Regional Cancer Center of Ukraine. “In the city of Kyiv, with an approximate population of 3 million citizens, three oncology centers are providing just emergency care and outpatient chemotherapy.
“Doctors who work in the epicenter of military actions are facing extreme psychological pressure, and even threat to their lives.”
Hrynkiv spoke at a March 10 meeting that convened global and regional cancer organizations—including American and European groups—to develop a cancer support network for Ukrainian refugees. More than 220 individuals from 30 or more cancer groups, professional societies, and companies attended the meeting.
The network, launched March 9, is led by the European Cancer Organisation, the American Society of Clinical Oncology, and the World Health Organization.
Other U.S. organizations in attendance at the ECO-ASCO meeting include the American Cancer Society, which has set up a care hotline (The Cancer Letter, March 11, 2022), and St. Jude Children’s Research Hospital, which is facilitating evacuations and triage on the ground in Ukraine (The Cancer Letter, March 4, 2022).
The design of the ECO-ASCO endeavor is similar to an 2020 ECO initiative, which created a network to respond to COVID-19. That network collated data on the pandemic and amplified efforts to address unmet needs.
ECO and ASCO are urging cancer groups that are able to contribute services, resources, or contacts to join the network, which can be accessed here.
The Cancer Letter’s compilation of resources, provided by governments and cancer and healthcare organizations, is available here.
The co-chairs of the ECO-ASCO network are ECO President Andreas Charalambous, ASCO President-Elect Eric Winer, and Richard Sullivan, a member of the WHO Emergency Committee. The network’s organizers said additional cancer groups are encouraged to join.
The initial objectives of the network are focused on:
- Creating a community for sharing of intelligence, experience and contacts,
- Providing an information hub of resources and links in national languages, signposting and amplifying work being done for Ukrainian patients,
- Gathering intelligence to inform advocacy work on the issue with the World Health Organization and the European Union,
- Coordinating, communicating and connecting organizations and people within the network, and
- Evolving over time, as the needs of other organizations are identified and addressed.
“We aim to be inclusive. Everyone is invited,” Julie Gralow, ASCO chief medical officer, said at the meeting. “The network wants to inform our advocacy work on the issue with the WHO, the EU and with national governments, so we’re working on advocacy as well.”
ASCO’s European counterpart, the European Society for Medical Oncology, is also leveraging its broad network of members and industry partners to provide onsite and remote support. ESMO leaders note that in addition to a large faculty with expertise across all diseases, the organization has 340 members in Ukraine, 500 in Romania, 200 in Poland, 100 in Bulgaria, 20 in Moldova, and 500 in Russia.
ESMO members who are willing to participate are expected to be able to provide advice and consult with physicians or healthcare workers who require clinical expertise or input. The society’s annual meeting, scheduled to take place in Paris this coming September, may also be used to facilitate networking and strategic responses to the Ukraine crisis.
The ECO-ASCO network will function as a hub that can be used to direct healthcare workers and patients to information across multiple languages, and, additionally, to assist cancer groups and oncology professionals in Ukraine and across Europe in real time.
Sources say that at least 20 patient advocacy organizations—members of ECO’s Patient Advisory Committee—are moving “at breakneck speed” to collect primary data through numerous networks on the ground in conflict zones and across Europe. These data, as well as contacts and resources, are then immediately shared across the networks.
Oncologists in Kyiv and Kharkiv say that although cancer services are significantly reduced, patients are still being treated at centers in these cities. Cancer care at other hospitals in major war zones have been halted, and healthcare infrastructures overall, including cancer services, have reached a critical stage and are collapsing or have been destroyed.
In Kyiv, the National Cancer Institute and Kyiv Cancer Center continue to provide limited chemotherapy services. Ukrainian sources say the Institute for Medical Radiology and Oncology in Kharkiv continue to function, despite severe bombing and missile attacks. Alas, not all the institutes of the Ukrainian National Academy of Medical Science are operational, and efforts are underway to assess their current state and needs.
In western Ukraine, where refugees have flocked in a desperate exodus, cancer services are fully functional. However, physicians and hospitals are overwhelmed by the sheer number of internally displaced persons—anticipated to increase to 10 million or 14 million over time—and patients who have crossed the border often reach perplexed healthcare workers who have no access to medical records and face language barriers.
How western Ukrainian cancer centers are being restocked and replenished or are retaining human resources is a more difficult challenge than managing refugees with cancer, experts say.
Health professionals in Ukraine are urging neighboring countries and emergent refugee health services to employ oncologists and physicians who have left for western Ukraine, and to provide essential chemotherapy drugs for patients.
Ukrainian oncologist Andriy Hrynkiv’s remarks at the ECO-ASCO meeting follow:
Dear colleagues, first of all, thank you all for coming here today. Let me please introduce myself. My name is Andriy Hrynkiv. I am a surgeon/oncologist at the Lviv Regional Cancer Center of Ukraine. On behalf of my country, I want to express my gratitude for all the support we are receiving from you and the countries you represent.
During my talk, I will shortly characterize the current state of the oncological service in Ukraine. Also, I will highlight the most important, in my opinion, issues that Ukrainian refugees are facing. I will start with the current situation in the countries nearby that hospitality provided shelter for our citizens.
First of all, I’d like to give you an overview of some numbers: 2 million citizens fled the country due to the hostilities, 1.2 million of them settled in Poland, 200,000 in Hungary and 130,000 in Slovakia. The most important problems are oncological patients abroad are facing a lack of information support in Ukrainian language.
In my opinion, it will be useful to perform screening at the border, just a small poll regarding their health condition, maybe even provide them with a small printed material in Ukrainian containing information regarding coordinating centers and contact persons who could direct persons to the appropriate hospital. During our last regional council meeting, a good idea was presented regarding the creation of website and phone line for Ukrainian refugees in Europe.
The second issue is a translation of Ukrainian medical documentation, and we are receiving a lot of help from our medical students who wanted to participate in our common goal. I will leave the suggestions open for subsequent discussion and will switch to the current situation in Ukraine, because it’s the main part of my topic.
Due to the hostilities, more than 60 hospitals were badly damaged. Yesterday during the preparation of my talk, I received information that maternity hospital No. 2 in Mariupol was destroyed due to the rocket fire, many injured people. All scheduled oncological care is stopped across the country due to the need of being prepared to receive a lot of injured.
In the city of Kharkiv, with an approximate population of one and a half million citizens, the one oncological hospital is destroyed, the only hospital in this area. In the city of Kyiv, with an approximate population of 3 million citizens, three oncology centers are providing just emergency care and outpatient chemotherapy. Doctors who work in the epicenter of military actions are facing extreme psychological pressure, and even threat to their lives.
Most of the internal displaced persons are concentrated in the west of Ukraine, because this region is thought to be relatively safe. Only the city of Lviv provided shelter to more than 200,000 internally displaced persons.
But even though west is thought to be relatively safe, we often hear sirens announcing an air alarm, and we have to evacuate our staff and our patients to the bomb shelter. So these patients, some of these patients aren’t able to walk, and only surgeons in the OR are still working under conditions like this.
In Ukraine, 150,000 new cases of malignant disease are diagnosed annually. Due to the pandemic, the number of stage III, stage IV cancer patients who need extensive treatment has significantly increased in the recent years. Historically, 9,000 from this number were diagnosed in the west, in our region. But due to the aforementioned, the load will increase dramatically.
The greatest burden will fall on the institution where I work, Lviv Regional Cancer Center, because it’s a large oncological center in Western Ukraine. Just in the recent days, the number of consultations in our hospital has multiplied by three. Our country was just at the beginning of medical reformation. This is why most of the hospitals didn’t receive medication for the following year.
A lot of warehouses with medicines were destroyed or are unavailable due to logistic problems. As follows, we are facing the serious problem due to the lack of medications and supplemental materials, like suture materials. Moreover, these drugs aren’t even commercially available.
To solve this issue, we need your help. Currently, our hospitals are able to provide the listing of the most urgent medications and supplemental materials we need to maintain the functioning of Ukrainian oncological service.
To resolve the situation, the government of Ukraine has signed a decree that allows importing medications in the country under the simplified procedure, including those not yet certified in Ukraine. It simplifies the procedure of receiving humanitarian aid from abroad dramatically.
Thank you very much in advance and looking forward for our communication and for your support.
Status reports from WHO, EU
At least 2.316 million Ukrainian refugees have, at this writing, exited the western borders of the country, WHO officials said.
“The extraordinary damage to health care and to cancer centers the Russians are undertaking within Ukraine are in massive violation of international humanitarian law in terms of attacks against hospitals and attacks against humanitarian convoys,” WHO’s Sullivan said at the meeting.
Current estimates suggest that there may be between 4 million and 5.4 million refugees eventually needing assistance outside Ukraine, and about 12 million to 13.5 million internally displaced people—predominantly from the northern, eastern, and southern parts of Ukraine.
“We’ll be packed into the west of Ukraine. These are truly massive, massive numbers,” Sullivan said. “This is the fastest displacement, both internally and externally, that we’ve seen since the Second World War, and the numbers that the immediate host countries are having to cope with are truly astronomical.
Doctors who work in the epicenter of military actions are facing extreme psychological pressure, and even threat to their lives.
Andriy Hrynkiv
“It should be said, though, that the movement of the refugees at the moment is still very, very dynamic. About 40% are moving on from their primary country of arrival, and of course, this is creating a lot of logistical problems in tracking those patients.”
International humanitarian and health care groups seeking to help Ukrainians can draw lessons from the Syrian refugee crisis, experts say. The response to Syria was marred by massive failures in the tracking of intelligence where it pertains to health care, particularly cancer care and palliative care—which at the time were not prioritized by the United Nations High Commissioner for Refugees.
“I think I just want to reinforce the fact that the people on the call today, ECO, ASCO, WHO, they’re going to be absolutely crucial in ensuring the best possible care for cancer patients, because, frankly, the other humanitarian agencies really have their hands full with other priorities,” Sullivan said.
A sustained response to the Ukraine crisis needs to include a long-term view of the management of cancer patients in the refugee population, from emergency support systems during the war through to the reconstruction of the Ukrainian cancer care ecosystem, Sullivan said.
But for now, the key issues are: 1) the generation of high resolution cancer intelligence, within and outside of Ukraine, and 2) the capacity and capability of host countries for handling the unprecedented influx of patients.
“In terms of serious medical conditions, very little data is currently being picked up,” Sullivan said. “This is something that is an action plan ongoing, because we know that about 9% of the refugees at the moment are coming across the border with serious medical conditions. There’s no further details on that, and 61% have absolutely no data, but again, that is work in progress.
“Looking at the estimates of what we could be dealing with in Europe in terms of refugees at T minus one month—T being 24th of February when Russia invaded Ukraine—we’re looking at anywhere between 8,000 and 12,000 cancer patients,” Sullivan said. “That’s both incidence and prevalence.
“Those are patients who have cancer and have a diagnosis of cancer who’ve moved across the border, and they know about patients who then present in one of these countries. That is a very large population within a month.”
In addition to cancer, there is an immediate mental health crisis within the Ukrainian refugee population, which has been heavily exposed to violence.
“They’ve been separated in many cases from loved ones and family members,” Sullivan said. “We have huge numbers of children who are on their own. Most of the refugees at the moment are women, children, and old men. We are already picking up significant mental health conditions.”
EU member states have been sending medicines and medical devices to Ukraine and to refugees in neighboring countries since Feb. 27.
“There is an unprecedented level of coordination that is needed and unity. Unity in terms of sanctions, unity in terms of support,” said Sandra Gallina, director general of the European Commission’s DG SANTE, or Directorate-General for Health and Food Safety. “We have many requests from Ukraine, mainly for personal protective equipment, diagnostic material, vaccines.
This is the fastest displacement, both internally and externally, that we’ve seen since the Second World War, and the numbers that the immediate host countries are having to cope with are truly astronomical.
Richard Sullivan
“We are helping the neighboring countries with €90 million of emergency programs to help the civilians affected in the war in Ukraine. We help the people in Ukraine. We help the people in Moldova, and we will mobilize €500 million for response activities dealing with the humanitarian conservancies of the crisis.”
The European Commission also channels private donations to Ukrainians in need—primarily through Belgium as the repository of funds. Donations will be shipped with a carrier paid by the EC to a dedicated network of coordinators in the border regions.
The EC is putting in motion plans to evacuate Ukrainian patients to hospitals across EU states in order to ease the pressure on eastern EU countries with health systems that are overloaded.
“We have a very good system, which functions. EU member states are offering what they can and member states can ask support for patients—all types of patients, including cancer patients, including those that are in need of medical evacuation and a receiving country is always easily found,” Gallina said. “So, it’s important that there is someone helping compiling this in the places where the refugees arrive. The information is totally secure because this system is securitized
“We have 20 years of experience dealing with these emergencies. And I want to put this platform at the service of our friends from the cancer network.”
For instance, there may be over 1,400 Ukrainian children with cancer in pediatric hospitals across the region. If any of these patients need to be moved, names must be provided and an evacuation or transfer can be requested at the border posts, or internally from Ukraine.
“We have 15,000 beds that have been offered by the hospitals in Europe, but these beds are empty, or we have very few requests because we can’t get the triage right and we can’t get the people right. So, it’s important that we help each other,” Gallina said. “I’m very grateful to the neighboring states, Poland, Romania, Hungary. And I would put for good measure, also, Moldova. Slovakia is also doing sterling work.
“But we need your help to reach all the cases that can be reached. We need the help of everyone.”
Updates from neighboring countries
Czech Republic
The Czech Republic has received more than 200,000 refugees—80% women; 14% children. For Ukrainian patients in need of care, particularly for acute conditions, including cancer, a visa can be obtained without delay.
Although hospitals have not exceeded full capacity, Czech sources anticipate that it may be necessary to re-distribute refugees that require highly specialized care in the future. Conducting cancer screening may not be possible at border crossings, officials say. Instead, screening for serious health problems may be more feasible so that first aid and lifesaving triage can take place.
At the moment, there is a greater need for establishing distribution channels for Ukrainian refugees across more European countries, Czech sources say, and a central website or coordinating center for Ukrainian cancer patients would play an essential function.
There are contact points in the Czech Republic that assess Ukrainian refugees for active cancer treatment so that they can be sent to cancer centers, where interpreters are available.
As is the case in Romania, Czech healthcare workers are finding that patients often have limited knowledge of the treatments they have received. Frequently, medical documentation isn’t available, which makes necessary therapeutic interventions risky.
The Organisation of European Cancer Institutes has been an effective partner to governments in the region in coordinating the transfer of cancer patients from the Polish frontier or other borders to other cancer centers that are members of OECI. More information may be available on the OECI website.
Hungary
Hungary has received more than 200,000 Ukrainian refugees to date. To manage the surge of cancer patients, the National Oncology Centre in Hungary has set up an information line and email address for patients, physicians, and institutions to coordinate care, oncologists in Hungary say.
Refugees who settle down with a temporary address in Hungary receive health care in regional hospitals assigned to the address.
The Hungarian Oncology Network connects hospitals and physicians, and patients are referred as needed. As is the case in other countries, there is an urgent need for medical documentation and translation services. A central interpreter line is run by the chief medical officer of Hungary.
Although capacity isn’t currently an issue for Hungary, surgical departments are facing a bottleneck.
A robust system for referrals and transfers doesn’t currently exist for patients who need to be evacuated or who require urgent specialized care, including specific cancer care.
Health professionals expect a need for an intergovernmental network and a centralized or federated platform to coordinate relocation or evacuation of patients.
Poland
Poland has received about 1.5 million Ukrainian refugees as of March 10. Sources in Poland say many require immediate medical aid, including cancer therapy. Patients are offered free therapy in Poland, including medications.
There is one drawback: Poland’s healthcare system is now oversaturated and officials are calling for the creation of a pan-Europe database that will allow institutions to expeditiously transfer patients to receive cancer treatment in other European countries. Many Ukrainian refugees have limited or no resources, which means countries and health systems must be prepared to cover travel and accommodation costs.
Also, the database must be able to provide access for patients in Ukraine—who are no longer able to receive care at local institutions—and enable providers to mobilize resources and move or evacuate patients to neighboring countries for cancer care.
Currently, there are two call centers that provide services in the Ukrainian language, and plans are underway, in partnership with NGOs and the National Health Fund, to provide cancer care resources and information to Ukrainian patients who are arriving at reception points.
While transportation to Ukraine is being arranged for medicines and cancer drugs, officials are running into legal barriers—some medications can’t be exported without special arrangements, which is making it difficult to get these supplies to Ukrainian patients.
Romania
The Romanian government is working on bringing supplies into Ukraine, because of disruptions to supply chains across the region for medicines and medical products.
Romanian officials say a hub has been created in northeastern Romania, which facilitates the logistics and transportation of medicines, medical equipment, and other materials—including for cancer patients at the border and in Ukraine.
The Romanian authorities have adopted legislation allowing all Ukrainian refugees and cancer patients to benefit from the country’s medical services and assistance plans. Officials are exploring additional opportunities for supporting Ukrainian patients and to play a role in the wider European international medical network.
Sources in Romania’s hospitals report a rapidly increasing number of Ukrainian cancer patients, some without medical records, which points to a need for greater connectivity and coordination with oncologists and remaining cancer networks in Ukraine.
Hospitals in Romania are calling for support, because they are starting or resuming chemotherapy and systemic treatments for patients—both in neoadjuvant and adjuvant settings—while also contending with providing sustenance and housing for children and families.
Slovakia
Although the Slovak Republic’s border with Ukraine is the narrowest among all neighboring countries, healthcare workers are having a difficult time with triage—identifying which Ukrainian patients require urgent care—because of a dearth of medical records and medical literacy.
Slovakian sources are also calling for greater regional coordination, because the country’s health system has a limited capacity, even prior to the crisis.
For now, all Ukrainians are able to receive free health care for urgent conditions for 30 days. There are co-pays for refugees who are transiting through Slovakia, whose destination is another country.
However, asylum seekers and Ukrainians who request temporary shelter or longer-term residence will be reimbursed for all necessary services.
Slovakian physicians and oncologists are now triaging cancer patients, including children, to pediatric hospitals and to the National Oncology Institute, for treatment and surgery. Conversations are underway to arrange transfers to neighboring countries once capacity is reached in Slovakia.
