Since Russia invaded Ukraine on February 24, the number of attacks on health-care facilities continues to mount. According to the World Health Organization (WHO), as of March 16, there have been 43 attacks on health facilities, including 34 attacks that have directly impacted health facilities and 7 that have impacted medical supplies. According to WHO’s Director General Tedros Adhanom Ghebreyesus, PhD, more than 300 health-care facilities are located in combat zones or in areas that Russia now controls. An additional 600 facilities are within 10 kilometers of the conflict line.1
“WHO’s priority remains to support health workers and the health system to continue to provide care to meet immediate health needs,” Dr. Ghebreyesus, said during a press conference. “We have now established supply lines to many cities of Ukraine, but challenges with access remain.... We are coordinating the deployment of 20 emergency medical teams of experts from many countries, pending a formal request for assistance from Ukraine’s Ministry of Health. And we have opened a field office in Poland to support our operations in Ukraine and to coordinate the response to the health needs of refugees.”
In reaction to the Russian invasion of Ukraine, following discussions with WHO, the European Union (EU) Commission, and the newly formed ASCO–European Cancer Organization (ECO) Ukraine Steering Committee, the ECO Board and ASCO have launched a special network (asco.org/Ukraine; europeancancer.org/topic-networks/20:impact-war-in-ukraine-on-cancer) to develop and coordinate a centralized resource center for Ukrainian patients with cancer and for those fleeing to bordering countries to help them continue receiving cancer care. The special network is also tasked with creating a support network for oncology providers both in Ukraine and in neighboring countries.
Although the exact number of patients receiving cancer care before the war is uncertain, Ukraine, with an estimated population of 44 million prior to the Russian invasion, in 2020, had a high cancer burden of nearly 163,000 new cases of cancer and more than 84,000 deaths from the disease.2 The country also has one of the highest childhood cancer mortality rates globally, and it is estimated that at the start of war, more than 1,500 children with cancer were receiving treatment.3
According to the latest figures from the United Nations High Commissioner for Refugees, Filippo Grandi, about 10 million Ukrainians have been displaced to other parts of the country,4 and more than 3.3 million refugees have poured into surrounding countries, with the vast majority, more than 2 million, escaping to Poland.5
Establishing a Network of Oncology Volunteers
Just days after the start of the Russian invasion of Ukraine, ASCO, together with its partners the American Cancer Society (ACS) and the Sidney Kimmel Cancer Center–Jefferson Health, launched the ACS Clinician Volunteer Corps 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. The ACS National Cancer Information Center has also expanded its 24-hour hotline to include toll-free numbers in Ukraine and bordering countries, where patients, caregivers, and oncology professionals can call for information.
ASCO members interested in volunteering to help respond to queries coming into the ACS National Cancer Information Center or in other volunteer opportunities may contact ASCO directly at international@asco.org.
In addition, ASCO has developed patient resources for Ukrainians on its website Cancer.Net, which includes information by Fay J. Hlubocky, PhD, MA, Cancer.Net’s editor for psychosocial oncology, on coping with the psychological impact of cancer on displaced patients.
The ASCO Post talked with Julie Gralow, MD, FACP, FASCO, Chief Medical Officer and Executive Vice President of ASCO, and Doug Pyle, ASCO’s Vice President of International Affairs, about ASCO’s efforts to harness international collaboration to support Ukrainian patients, refugees, and oncologists in Ukraine and in bordering countries.
Julie Gralow, MD, FACP, FASCO
Doug Pyle
Coordinating Oncology Resources in Ukraine and Across Eastern Europe
How is ASCO coordinating resources and information with other cancer organizations and societies to assist patients with cancer and oncology providers in Ukraine and across Europe in real time?
Dr. Gralow: Our main strategy is partnership and collaboration and working with others to maximize our efforts and reduce replication of efforts. After the Russian invasion of Ukraine, we very quickly partnered with the ACS in two areas. First, was on providing resource materials for patients and caregivers, including ACS local call center numbers in Ukraine, the surrounding countries, and the United States. We have also created specific information by Dr. Hlubocky, “Coping With War and Cancer: How to Take Care of Your Mental Health During the Ukrainian Crisis,” on our patient website Cancer.Net. The piece has been translated into Ukrainian, Hungarian, Polish, Romanian, and Russian. We are promoting the efforts of the ACS, and the ACS is promoting ASCO’s efforts.
Second, the ACS has established a 24/7 hotline with its National Cancer Information Center, where patients and caregivers can be connected to a network of volunteer clinicians. The first example we were given of its use was a call from a general practitioner in a bordering country saying he had a patient with cancer show up at his clinic. The patient had been treated with radiation therapy in the previous week, and he wanted to know whether the patient was still radioactive and what he should do with the patient.
Having oncology experts answering these calls is very helpful. We have been helping the ACS staff that volunteer oncology clinician group, starting with physicians who speak the local languages.
Next, there is ASCO’s collaboration with the ECO, which is an umbrella organization for both European professional organizations and patient organizations. The ECO reached out to us, and we have a great partnership with them. We have created a steering group, which meets regularly and advises each other on the evolving crisis. We have broadened that effort into a special network, which currently includes ASCO, ECO, WHO, the EU Commission, and many other European cancer organizations, and others are welcome to join.
Mr. Pyle: Because ECO includes virtually all major cancer organizations and patient groups in Europe, it is the perfect partner to coordinate a patient and provider response to the Ukraine crisis. The special network has brought together not only organizations in the ECO, but the WHO, and the EU Commission, as well, and others are joining in.
Recently, we had inquiries from Doctors Without Borders and Direct Relief about deliveries of medical supplies and cancer medicines to Ukraine, and we’ve invited them to join the special network. So, together we have rapidly formed an umbrella entity to coordinate a humanitarian response to the war capable of delivering much needed assistance, including patient materials, professional expertise, supplies, and medicines.
Because the European Cancer Organization includes virtually all major cancer organizations and patient groups in Europe, it is the perfect partner to coordinate a patient and provider response to the Ukraine crisis.— Doug Pyle
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In fact, we’ve heard that the WHO is incredibly grateful to ECO and ASCO for putting together this network so rapidly, because it has really helped WHO coordinate its efforts as well. As the needs of patients and oncology providers affected by the war are identified and prioritized, that is where the special network will spring into action and help us channel resources to those most in need.
In terms of how we are responding to this crisis in real time, the psychosocial information on Cancer.Net is a good example of how quickly we acted once we heard from one of our members in Romania, Dr. Nicoleta Antone, who identified the need for psychosocial resources for Ukrainian patients and refugees. Cancer.Net worked with volunteers to create that resource and got the information translated into several languages and posted to the website within a few days.
To the extent that the development of resources can be in real time, that is pretty quick, and it shows the direct communication channel from the field to us and back to the field.
ASCO Members in Action
How many ASCO members are in Ukraine and in the surrounding countries? How are ASCO members in these countries coordinating responses to the war?
Dr. Gralow: We have about 40 active members in Ukraine, most of whom are in Kyiv, Lviv, Odesa, Kharkiv, and Dnipro. We have 919 ASCO members in Eastern and Central Europe. For example, there are 121 members in Romania, and 63 in Poland, which are the two countries currently housing the most refugees.
In terms of a coordinated effort, again this is where the ECO collaboration is key, because we can bring ASCO members into the fold along with these other organizations. For example, members can link up with the patient organizations within the ECO and direct patients to the appropriate treatment centers.
Meeting the Urgent Needs of ASCO Members in Ukraine
What are you hearing from Ukrainian members regarding how ASCO members in the United States and throughout the world can assist them? What are their greatest needs: medicines, more oncology providers in host countries?
Dr. Gralow: Their needs are evolving, and they are going to be different as the war goes on. What we heard first from our members as we reached out to them within Ukraine was “thank you so much for your support. Even just your emotional support and knowing that you are thinking of us is incredibly spirit lifting.” So, their first thought was thank you for supporting us, thank you for thinking of us, and not leaving us by ourselves.
Right now, there are more than 3 million Ukrainian refugees and another approximately 10 to 12 million Ukrainians who have been displaced within the country and have moved from the East, North, and South of Ukraine to the West. There are a lot more displaced people in western Ukraine needing cancer care than there are refugees in other countries. But the situation is very fluid, and it’s likely that many of those displaced people will become refugees over the next weeks.
We have already heard that the health-care system in Moldova, which is on the border of Ukraine, has already reached capacity for caring for extra patients. We receive regular updates from our colleagues in Ukraine, Romania, and Poland about the increasing numbers of refugee patients flooding into neighboring countries.
Do our colleagues in these countries need cancer medicines? Yes, but where and what cancer centers are needed change daily. It’s possible there are plenty of medicines in certain regions where there are no longer patients that could be shifted to other places, but with the war raging, we don’t know the exact situation.
We are in conversations with Doctors Without Borders and Direct Relief to come up with a coordinated way to take requests for medicines. Direct Relief is good at getting medical supplies into countries, but it doesn’t have people within those countries to distribute the supplies. Doctors Without Borders has physicians on the ground in these countries, but they are not oncologists. In our partnership with ECO, along with these two organizations and our members in these countries, we can help sort out the medical priorities in these countries.
We are also working with groups to determine, for example, how to transfer patients needing radiation therapy or surgery to another country for treatment.
A big problem is receiving medical information from patients, because many do not have any medical records and do not know their medical history in detail and may not even know the name of the medications they are taking. We are also sorting out how to help patients reconnect with their health-care system to at least get some information for the doctors who are taking over their care.
Translating the information into other languages has been identified as a great need, and we have had a great outpouring both from our ASCO members and our ECO members, as well as physicians in Ukraine, who want to volunteer to be translators and medical interpreters for patients who are fleeing to bordering countries.
Mr. Pyle: In the fact-finding state we are in right now, we are hearing from members in Ukraine about their medical needs, the inability to track patients, and the lack of medical records. We are also hearing from members in border countries that they will soon be overwhelmed with the number of patients moving into their countries. The WHO and the EU are starting to look at whether there are countries in Western Europe to which some of these patients can be relocated for treatment.
Richard Sullivan, MD, PhD, Director of the Institute of Cancer Policy at King’s College London, and a member of the World Health Emergency Committee, is heading up this effort and is having coordinated discussions with the Organization of European Cancer Institutes to determine where refugee patients might go for cancer care.
A lot is influx right now, but we are starting to get a better handle on what the specific needs are of these patients and some potential solutions.
Creating a Medical Registry for Refugees With Cancer
How are patients with cancer being tracked for care in other countries? Is there a registry being developed, and how will treatment costs be covered?
Dr. Gralow: We recently heard that the crisis intake form refugees must fill out at border crossings now includes a question about any serious health conditions, including cancer, so that is one way we will be able to keep track of the number of patients with cancer leaving Ukraine. Many people had already left the country before that question was added, so we won’t know the exact number of patients seeking care in other countries.
In terms of cancer costs, the European Union has guaranteed coverage of care incurred by refugee patients in the bordering countries and in countries further west, including the United Kingdom.
Mr. Pyle: I believe the health-care coverage is limited to 90 days. This is a very important issue to monitor, because if this conflict continues for many months, funding for cancer care and other types of care, such as housing, will run out, which is what happens in any kind of refugee crisis when the host country starts to look for longer-term solutions.
The Issue of Continuity of Care
How will it be possible to provide continuity of care for refugee patients if they do not have identification or current medical records with them or can’t receive the treatment they need in host countries?
Dr. Gralow: I agree. No one said solving this problem would be easy. There is also the issue of what happens to the men between the ages of 20 and 60 who are not allowed to leave Ukraine, due to the possible need for military conscription, and may have cancer or other diseases. The United Nations and WHO are investigating whether those patients can get a waiver to leave the country and receive treatment elsewhere, but they may have to stay in Western Ukraine for as long as possible.
Utilizing Technology to Facilitate Care for Refugees
Is there a role for technology, such as telemedicine, to facilitate care for patients in Ukraine and those in nearby countries?
Mr. Pyle: The topic of using telemedicine to improve care for these patients has come up and is still in the brainstorming stage. Telemedicine may be more applicable in the border countries to make continuity of care easier for refugees having to move from city to city or country to country, and it will be possible to have physician-to-physician consultation for patients.
The situation in Ukraine is just so severe right now, it is difficult to imagine many oncologists there having a Zoom call, for example, with an oncologist in another country treating his or her patient. But I can imagine a situation in which a physician treating a refugee patient in Romania could use telemedicine or Zoom to consult with oncologists now treating the patient in another country.
We want to provide the help that is needed, and we are listening to what is being asked for in the region.— Julie Gralow, MD, FACP, FASCO
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Dr. Gralow: We have had conversations with contacts in some major cancer centers in the United States who want to help, and we are trying to figure out what the need is and how to provide resources.
Everyone wants to help, and we are feeling good that so many are reaching out. We want to provide the help that is needed, and we are listening to what is being asked for in the region.
DISCLOSURE: Dr. Gralow has served as a consultant or advisor to Genentech, AstraZeneca, Roche, Novartis, and Seagen. Mr. Pyle reported no conflicts of interest.
REFERENCES
1. World Health Organization: WHO Director-General’s opening remarks at the WHO press conference—March 16, 2022. Available at https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-who-press-conference-16-march-2022. Accessed March 24, 2022.
2. International Agency for Research on Cancer: Ukraine: Globocan 2020. Available at https://gco.iarc.fr/today/data/factsheets/populations/804-ukraine-fact-sheets.pdf. Accessed March 24, 2022.
3. Bin Han Ong M: As bombs fall, international efforts are ramping up to help Ukraine’s cancer patients, doctors, and refugees. The Cancer Letter. March 4, 2022. Available at https://cancerletter.com/the-cancer-letter/20220304_3/. Accessed March 24, 2022.
4. Tweet from Filippo Grandi. Available at https://twitter.com/FilippoGrandi/status/1505455082778812417. Accessed March 24, 2022.
5. United Nations High Commissioner for Refugees: Operational Data Portal: Ukraine Refugee Situation. Available at https://data2.unhcr.org/en/situations/ukraine. Accessed March 24, 2022.
