Chemotherapy at Ukraine’s National Cancer Institute in Kyiv no longer has to be administered in underground bomb shelters.
Oleksandr Stakhovskyi, a urologist and oncologic surgeon at the institute, said cancer care in Kyiv is gradually returning to some semblance of normalcy, as patients who fled the city during the initial Russian invasion are returning.
The Ukraine NCI is resuming routine cancer treatment at limited capacity, he said.
Stakhovskyi spoke with The Cancer Letter last month, noting that “if your city is under fire, nobody’s caring about oncology” (The Cancer Letter, March 4, 2022). Since then, the situation in Kyiv has changed for the better, Stakhovskyi said in a follow-up conversation April 6.
Stakhovskyi estimates that at least 70% of his previously scheduled patients have returned for care in recent weeks.
“My oncological urological patients, I’m seeing them coming back more and more,” Stakhovskyi said to The Cancer Letter. “I have patients even calling from western centers when they have problems with the surgery, to come back here to Kyiv, because we’re the National Cancer Institute, so we can do more complicated cases.”
As the war continues, NCI is currently housing about 10 injured soldiers.
“We are just bandaging and taking care of their wounds,” Stakhovskyi said. “So, it’s not really the work you are supposed to do in a National Cancer Institute.
“Since in Kyiv there are only two big military hospitals, they were expecting to do some serious surgeries—they tried to freeze their beds just for patients. Those patients never came, but we already have those soldiers and we will not kick them out right now. They will stay in our cancer institute for some time. We’re not going to transport them because we are already keeping them until the situation will be super safe.”
The Russian invasion of Ukraine has also shifted the demographics of the oncologists available to treat patients in Kyiv. Men between the ages of 18 and 60 are required to stay in Ukraine, meaning only women doctors are able to leave the country.
“We have at least three or four different associations or organizations who started to open hubs to receive resumes and CVs of our doctors, to try to help them enter other European countries’ systems, if they are already refugees, if they’re already dislocated from Ukraine,” Stakhovskyi said. “I’m definitely motivating all my younger female doctors whom I talk to, that it’s a good opportunity to go and get a fellowship.”
Basic cancer drugs are available in Kyiv, in part thanks to humanitarian aid, and oncology centers have been sharing drugs within the country as needed. But for cities under Russian assault or occupation—Mariupol, for example—the situation is murkier.
“The major problem right now is for those cities that are blocked, that you are not able to get humanitarian aid into, or to get patients out safely,” Stakhovskyi said. “At that moment, you realize that it’s not even about cancer, it’s about survival.”
Stakhovskyi said he is aware of some surgeons proceeding with surgeries they have little experience with, since it’s impossible to transport patients out of the city.
“That’s what is happening right now, is that even though those cities are semi-blocked, they’re still finding a way of doing surgeries,” Stakhovskyi said. “That sounds kind of crazy when you are sitting somewhere in the States—doing surgeries when you have a war next to you. But I think that’s what’s happening here. Everything is relative to the situation we have around.”
Humanitarian efforts to support cancer patients have also been solidifying, Stakhovskyi said. For example, St. Jude has partnered with Polish and Ukrainian foundations to evacuate pediatric cancer patients from the country (The Cancer Letter, March 4, 2022).
Stakhovskyi spoke with Alice Tracey, a reporter with The Cancer Letter.
Alice Tracey: First of all, how are you? How are things at the National Cancer Institute, and how have things changed since we last spoke?
Oleksandr Stakhovskyi: We are—in Kyiv, I mean—I’m okay. Everything is good. We are still working in the National Cancer Institute. Not like we did before—in this worse situation, we are sheltering some military patients.
So, we are devoting a number of our working hours to take care of wounded soldiers. But since we are in Kyiv, and we are not specialized as a military trauma hospital, we have a few of them—I guess 10, maybe 11, not that much. But other than that, we still have our cancer patients back. Kyiv is getting more and more quiet.
I believe for the last seven days, I didn’t hear any bombing or any shooting. So, I didn’t hear any sounds of that in Kyiv. And I didn’t read any news that rockets did fly into Kyiv and either hit something or were put down by the system. So, in terms of war, it’s getting quiet.
According to our officials, the Kyiv region is, right now, free of enemy Russians. There are no Russians around, so they’re kicked out of the Kyiv region. They may dislocate somewhere else, but in Kyiv they say there are no Russians left—even though we still are kind of afraid of possible air attacks or missile attacks, because you always can throw rockets or bombs from the planes, from aviation.
I’m not a military strategist, but it just seems irrational, because every rocket you are shooting, every bomb, you are paying money for that. So, if you just need to frighten people, that’s one thing. Our anti-missile system is working. But, if you don’t have any enemies around the city, just bombing the city will kind of be useless, because you are not able to kill all the people with only bombing. You need to invade the city.
But if there is nobody around, you’re not—and Ukraine is a big country, so it’s not like you take your plane, and in 20 minutes, you’re next to Kyiv with all your batteries. It doesn’t seem the Russian army is able to do this kind of attack on Kyiv. That’s why we are quite secure right now, and Kyiv is reviving a bit. So, people are returning to Kyiv.
Right now we have a traffic jam into Kyiv.
Oh, interesting.
OS: Our mayor of the city is saying, “It’s not yet safe, please stay away for another week out of the city.” People are still returning to the city.
What about cancer patients? Are you seeing more cancer patients and more of those routine treatments?
OS: That’s the most fun part right now. I mean, not fun—but remember, I’m a surgeon, so for me it’s a fun part. As I told you before, my OR plan was booked until the end of March, and what I’m seeing is that at least 70% of my patients came back to me.
Wow.
OS: I lost only 30%. I have a couple of patients that were operated on in Lviv, which is the western oncocenter I told you about. We have around seven or eight oncocenters in the western part of Ukraine, which were not affected by the war at all, so they’ve continued their routine work, just with an influx of patients from other parts of Ukraine.
I have a couple of my patients who operated in those centers, but the other guys, usually cancer patients in terms of prostate cancer or kidney cancer, they postponed. They didn’t go out of the country—well, I don’t know about that, but I just found out that for the last couple of weeks I have almost all my patients who were booked for surgery, or they were already operated on by me within the last couple of weeks.
So, things are definitely changing.
OS: First of all, we have some part of our work which is devoted to our military soldiers, but since there are a few of them—as I told you, in our instance, there are less than 10, which we’re taking care of—it’s not hard surgeries. We are just bandaging and taking care of their wounds. So, it’s not really the work you are supposed to do in a National Cancer Institute.
But since in Kyiv there are only two big military hospitals, they were expecting to do some serious surgeries—they tried to freeze their beds just for patients. Those patients never came, but we already have those soldiers and we will not kick them out right now. They will stay in our cancer institute for some time. We’re not going to transport them because we are already keeping them until the situation will be super safe.
And, we’ve started to receive our cancer patients. We opened two surgical departments instead of seven, which we had before. So, every department was devoted to some specialty, like head and neck surgery, we had gynecology, we had urology, we had thoracic surgery, we had abdominal, and a coloproctology department.
Currently, we just have two departments. We have uro-gyno, and there are also mammology and soft tissue tumors in that department in terms of surgeons, and we have thoracic-abdominal, which takes care of tumors in the lungs and gastro tumors, esophagus and abdomen. It is surgical, they’re all surgical.
Our chemotherapy is currently fully loaded and fully working in an ambulatory clinic. I told you, I think, during my first interview, that we started doing chemo.
Nowadays, the chemo is more routine. So, more and more patients are coming back for chemotherapy. It’s almost properly working. I guess we are not doing those intense regimens—it’s usually simplified regimens for the whole bunch of oncological patients we had before.
I remember last time, some of that was happening underground because of the threat of bombing. Is that still the case?
OS: No, right now it’s totally normal in our ambulatory chemotherapy room, in nice chairs like we did before the war. It’s the same. Some patients are laying in bed, some sitting in the armchairs—really like before the war, as they did it prior. They did it five days a week.
Right now, it’s more and more patients coming, so more patients will receive the chemotherapy—they come, they take the drug, they go home.
I told you from a surgical standpoint, at least my oncological urological patients, I’m seeing them coming back more and more. I have patients even calling from western centers when they have problems with the surgery, to come back here to Kyiv, because we’re the National Cancer Institute, so we can do more complicated cases.
You said last time it was a lot of male doctors left behind—younger, male doctors, people who hadn’t left the city. Is that changing, the demographics of the doctors who are available?
Credit: Oleksandr Stakhovskyi
OS: That’s a funny story. Since everybody would like to help Ukrainians, what is happening right now is that our fellow institutions—European centers and even American centers—are starting to open positions for doctors in Ukraine, as research fellows.
But, since it’s only for girls, it’s kind of sexist. We are sending our girls out—I had a colleague who went to Germany for a two-year fellowship, and it was like a flash. She asked the professor, he said, “Yes, we can do it,” and next week she was already there. Everybody is so eager to help by opening positions.
And, really, we have at least three or four different associations or organizations who started to open hubs to receive resumes and CVs of our doctors, to try to help them enter other European countries’ systems, if they are already refugees, if they’re already dislocated from Ukraine.
But if you are in Ukraine, we can send only females, taking into account that it’s not going to be the same way of life we’re used to at least for the next year.
I mean, if you are a younger doctor, it’s definitely a good chance for you to go somewhere, to study something extra. That’s why I’m definitely motivating all my younger female doctors whom I talk to, that it’s a good opportunity to go and get a fellowship.
But you won’t be leaving anytime soon, it sounds like.
OS: I mean, I’m not young anymore, so I did my fellowships. I’m pretty confident with that. I feel that for myself, and there are a number of doctors in my institution who are already kind of established—so, we will not have a huge problem with getting patients.
Even though lots of people left Ukraine, you still have lots of cancer patients who stayed within the country.
And since I’m a surgeon, we know that surgery is still mainstream for the majority of cancer patients. We obviously have combination treatments, and, as I told you, chemotherapy is almost totally normal right now.
Our radiation program will start next week. So, in our institution, the National Cancer Institute, the radiation department will start to work like previously from Monday.
How are medical supplies looking? I remember last time there was some strain.
OS: That’s another issue that we had. Our ministry is very focused on what we are currently getting. We have tons of humanitarian aid right now. It’s not always the drugs we would like to receive, but again, when we are talking about cancer patients, you are not looking for a second or third or fourth line of systemic treatments.
You are still looking for basic regimens and for basic drugs. I mean, you don’t need immunotherapies, which are crazy expensive to bring to Ukraine, to give to a patient who is dying because he’s not responding to the second-line systemic treatment—ipilimumab or nivolumab, or very fancy new drugs.
So, when we are talking about the lack of drugs—I told you last time, we had MSD, who donated pembrolizumab or immuno drugs to Ukrainian patients. You have others who are still donating some other drugs, which are very expensive in Ukraine to patients.
But, since we know that this shift of patients from Ukraine, where lots of people left Ukraine already with cancer, the remaining part will definitely have enough.
We have nice communication between oncocenters and their chiefs. They have a system where they can share with each other if something is lacking in one region or fully loaded with medications, in Dnipro or Zaporizhzhia—they can always share.
The major problem right now is for those cities that are blocked, that you are not able to get humanitarian aid into, or to get patients out safely. That’s probably the major problem for all the cancer patients who are staying within those cities. At that moment, you realize that it’s not even about cancer, it’s about survival.
Patients and doctors and kids and families and civilians and armies are locked in one city, like Mariupol, for example, or Kharkiv—they’re always bombing Kharkiv, but we still have patients who are coming to our institution to receive drugs, and then they’re going back to Kharkiv because they live there, which sounds unusual, but it happens.
But what is happening in those crazy towns like Mariupol, which has been locked already for the last month, we don’t have any information out of there, we don’t have any possibility to bring out people, like civilians, so we are not even talking about cancer patients. We are not able to bring civilians out. So, in those cities, they will receive help within the systems they have left.
So, lots of variety, still, between different cities.
OS: Really, there is not a huge number of these occupied cities. We are talking only about, probably, Mariupol. We have limited connection and limited access to Kherson, and Mykolaiv, which is not very far from Kherson.
I was talking to doctors yesterday—they have a nice humanitarian supply and they have doctors working in the oncological service. The issue is just that it’s a little bit more dangerous than in Kyiv, but anyhow they still manage to do some surgeries.
We have nice communication between oncocenters and their chiefs. They have a system where they can share with each other if something is lacking in one region or fully loaded with medications, in Dnipro or Zaporizhzhia—they can always share.
I did talk yesterday with a general surgeon from Kherson—he was consulting with me about a patient with a tumor in his kidney.
I was saying, “I mean, if this resection may be done as a partial resection, perhaps it should be done lap [laproscopically].” And he’s saying, “I’ve never done lap.”
So I said, “Just send me the patient.” He said, “Oh, it’s impossible to send you the patient because we are locked. So, I may do an open surgery, because I have that experience.”
That’s what is happening right now, is that even though those cities are semi-blocked, they’re still finding a way of doing surgeries. That sounds kind of crazy when you are sitting somewhere in the States—doing surgeries when you have a war next to you. But I think that’s what’s happening here. Everything is relative to the situation we have around.
I think patients, if they’re not able to leave the city and they know they have a tumor, they go to the hospital. The doctor might say, “We are in the city and we are blocked, but you need my help. I will do this.”
They’re not supposed to shoot the hospital, because they have already blocked the city. So, I think somehow those doctors manage to go into surgery with their patients. But I don’t have a proper understanding, because I’m not there.
It’s hard for me to describe to you the reasons why in that kind of critical situation this doctor will go into surgery, even doing an unusual surgery for him.
I mean, by being a general surgeon, you will not do a kidney tumor, because it’s a partial resection. It’s a kind of bloody surgery that needs specific training. It’s hard for me to understand, but that’s what’s happening.
Is there anything that we’ve missed or anything else you’d like to share?
OS: We might talk about the humanitarian help which is coming from abroad. We are having loads of boxes from different centers to the National Cancer Institute.
We are sharing with other hospitals in Kyiv. We are able to send this humanitarian aid to Mykolaiv. The cities that really need that would be those that are currently blocked and locked, but again, that’s just two or three cities.
So, I feel that we receive a lot of help from outside, and people feel they help, because if they’re not able to come, they can send aid, or they can keep our patients—for example, they can give them surgeries.
That’s what I’ve heard from my colleagues from other specialties, that a number of the patients were operated on in Germany totally for free. Pancreatic cancers or big complex surgeries were already done for our patients somewhere in Europe, absolutely for free, because Ukrainians with cancer came to those centers. So that is happening, which is really nice of our European colleagues.
We have this huge initiative from St. Jude hospital, which is a children’s hospital in the States. They’re making a huge initiative with our ministry and our NGO, which is called Tabletochki, and they send all the kids with cancer away. They put them into some special hub hospital in Lviv.
Then, they send them to a Polish hub, and from the Polish hub, depending on the stage, depending on the disease, they translate all the medical information and distribute those kids across Europe. Some patients who really need it even flew to Canada or the States to receive oncological help, but that’s a totally different story. It’s definitely not my story.
That sounds very interesting. It seems that there’s been a big push to get pediatric cancer patients out of the country.
OS: Yeah. It’s kind of easier with them, you know? Because, when you have an adult patient, they can choose, they can say, “Oh, I don’t want to wait weeks, I will go to Germany, they will do it faster; I don’t want this guy, I read the news that that professor is bad or the surgeon is better; that treatment may suit me better.”
But with kids, it’s more parents who don’t know what to do. So, if somebody’s saying that St. Jude Hospital is a huge name, and they recommend this, everybody usually takes this as proper advice and follows the recommendation.
And since there are fewer kids, it’s definitely manageable numbers. It’s easier to organize all of them to hubs—just go in, translate their medications, and send them. And that’s it.
I think it’s more easy to organize because the whole mess of cancer patients as adults—some in remission, some in follow-up, some in an acute state, some in chemo, some whose chemo was suspended—it’s more hard to manage this mess and they are dislocated, so it’s different.
Thank you so much, again, and we’ll be in touch. Thank you for your time.
