We are all following the ongoing Russian invasion of Ukraine with surprise and horror. I’m sure few readers of The ASCO Post imagined the invasion of a European country by its European neighbor was possible again, naively thinking wars like this ended with the Allied victory in World War II. But then we witnessed Russia’s invasion of Georgia in 2008, and Crimea in 2014. And, sadly, here we are again.
The usual focus on the consequences of a war is on immediate casualties and deaths of combatants and noncombatants. In a situation like Ukraine today, with widespread civil resistance, noncombatants are quickly becoming combatants, blurring this distinction.
Oddly, the public health consequences of armed conflicts have received relatively little attention. Wars displace populations, upset or destroy health-care systems, disrupt social services, and increase infectious diseases transmission risk. I am tasked with trying to estimate the health consequences of this war on people with cancer whilst it is in progress and before the outcome is known. However, it’s possible to make predictions as to what might happen based on prior wars.
Robert Peter Gale, MD, PhD, DSc (hc), FACP, FRCPI (hon), FRSM
Data Limitations
It is theoretically possible to estimate cancer consequences of the war in Ukraine by comparing cancer incidences and death rates before and after the conflict, assuming a high-quality data-collection system was in place before the war began and will exist long after it concludes. The National Cancer Registry of Ukraine issued its most recent report in 2020.1 The registry is high quality. Other epidemiologic data from the Chernobyl State Registry of Ukraine were used to estimate leukemias in mitigation workers (“liquidators”) at the Chernobyl nuclear power facility accident in a case control study.2
There are, however, substantial limitations to using data of this type to estimate the cancer consequences of war. First, and probably most important, such systems stop functioning in a war and perhaps for a long while thereafter, depending on the war’s outcome. Another limitation is confounding by emigration. As many as 4 million people (10% of Ukraine’s population) are expected to flee to countries such as Poland, Hungary, and Romania. Many will never return to Ukraine.
Next, we have the problem of ascertainment bias. Screening and reporting of cancer incidences and deaths are unlikely to return to prewar levels for many years, if ever. Also, people with advanced cancers are the most susceptible to dying because they cannot be easily evacuated and, indirectly, because of susceptibility to infections. These considerations limit the accuracy of epidemiologic data to estimate cancer consequences of the war.
Further Complications
Several cancers often detected at an early stage by screening, such as breast, colorectal, prostate cancers, and melanoma, will be missed—the consequence of which is an initial decrease in these cancers followed by an increasing proportion of more advanced cancers and more cancer-related deaths.
Then there is the problem of interrupted or cancelled cancer care. People with cancer fear visiting hospitals and clinics during a bombardment. Hospitals and clinics that are open are overwhelmed treating civilian causalities, resulting in delayed or cancelled cancer surgeries, radiation therapy, and chemotherapy. Chemotherapy schedules are being interrupted. Access to imported anticancer drugs and to supportive measures—including antibiotics, red blood cell and platelet transfusions, and molecularly cloned hematopoietic growth factors such as erythropoietin and granulocyte colony-stimulating factor—has decreased or stopped.
These issues are not theoretical. They are happening today. The BBC reported that a 3-year-old child with neuroblastoma in Kharkiv is unable to continue her anticancer therapy because of a drug shortage. The family is fleeing to Poland.
Another consideration centers on cancers that might be caused by the war. For example, Ukraine has 15 operating nuclear power facilities along with several spent nuclear fuel storage sites. Destruction of any of them could result in the release of radioactive materials, increasing cancer risk in exposed persons. The Russian army has taken control of the decommissioned Chernobyl nuclear power facility and more recently of the Zaporizhzhya nuclear power facility. A nuclear fuel storage facility near Kyiv was bombed, as was an electricity-generating station near another storage facility. I and others have discussed nuclear risks of the war in Ukraine elsewhere.3-5 Cancer risks from the Chernobyl nuclear power facility accident have been discussed and debated, as have estimates of cancer risk from low-level ionizing radiations.6,7
Environmental and Lifestyle Issues
There are two more consequences of the war to consider:
- Environmental degradation
- Lifestyle changes associated with increased cancer risk.
Weapons used in modern wars pose substantial environmental risks for cancer development. One example is the use of Agent Orange in the Vietnam War, which the U.S. National Academy of Science and the U.S. Department of Veterans Affairs have associated with increased risks of sarcomas; lymphomas; plasma cell myeloma; chronic lymphocytic leukemias; and lung, prostate, and bladder cancers.8,9
Other exposures include mustard gas, arsenic, and asbestos. Modern tanks are clad in depleted uranium to deter penetrating artillery and missiles. Ironically, tank-piercing artillery also incorporates depleted uranium. There are convincing data from the Gulf and Balkan Wars of an increased cancer risk from depleted uranium, but this is controversial.10
One can easily imagine other toxic substances released into the environment by modern weapons. For the moment, I am ignoring the ultimate environmental and cancer hazard—the possible use of nuclear weapons, of which Russia has an estimated 5,977, including about 1,500 scheduled for decommissioning. It should be noted that environmental degradation also results in altered food supply and eating patterns, which impact cancer risk.
Soldiers and civilians alter their lifestyles during and after a war. Cigarette smoking and alcohol consumption increase markedly, which can be expected to result in more cancers over several decades.11
Conclusion
For the reasons I discuss it is likely we will never precisely know the cancer consequences of the war in Ukraine. However, care of Ukrainians with cancer will undoubtedly be degraded, and preventive cancer screening will stop. Several of the aforementioned factors make it likely that the invasion of Ukraine will result in more cancers and more cancer deaths. ASCO has issued a statement regarding the impact of war in Ukraine on people with cancer (see page 1).
The issues I discuss clearly indicate that more attention to the public health consequences of war is needed. Some estimates suggest there may be as many as nine public health–related deaths for every direct death in a war. For further reading on this issue, I recommend references 12 and 13.
Dr. Gale is Visiting Professor of Haematology at Imperial College London and a Foreign Member of the Russian Federation and China Academies of Science and Medical Science. Photo courtesy of Patricia Williams.
DISCLOSURE: Dr. Gale has received research funding from the UK National Institute of Health Research funding scheme.
REFERENCES
1. Federenko ZP, Michailovich YY, Goulak LO, et al: Cancer in Ukraine, 2018–2019: Incidence, Mortality, Activities of Oncological Service. Bulletin of the National Cancer Institute of Ukraine, Vol 21, 2020.
2. Zablotska LB, Bazyka D, Lubin JH, et al: Radiation and the risk of chronic lymphocytic and other leukemias among Chernobyl cleanup workers. Environ Health Perspect 121:59-65, 2013.
3. Ramberg B: Nuclear Power Plants as Weapons for the Enemy: An Unrecognized Military Peril. Berkeley, California: University of California Press; 1985.
4. Ramberg B: The Risk of Nuclear Disaster in Ukraine. Project Syndicate. Available at https://www.project-syndicate.org/commentary/ukraine-nuclear-reactor-risk-by-bennett-ramberg-2022-02. Accessed March 7, 2022.
5. Gale RP: The Russian invasion of Ukraine: Implication for hematologists and oncologists. The Cancer Letter 4:08, 2022.
6. World Health Organization: 1986–2016: Chernobyl at 30. Available at https://www.who.int/publications/m/item/1986-2016-chernobyl-at-30. Accessed March 7, 2022.
7. Committee on the Biological Effects of Ionizing Radiations: Exposure to Low Levels of Ionizing Radiation. BEIR V. Washington, DC; National Academies Press; 1996.
8. Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides: Veterans and Agent Orange, Update 11. National Academies of Sciences, Engineering, and Medicine, 2018.
9. U.S. Department of Veterans Affairs: Agent Orange exposure and VA disability compensation. Available at https://www.va.gov/disability/eligibility/hazardous-materials-exposure/agent-orange/#weve-added-3-more-presumptive. Accessed March 7, 2022.
10. United Nations Environment Programme Scientific Mission to Kosovo: Depleted Uranium in Kosovo: Post-Conflict Environmental Assessment. Available at https://www.iaea.org/sites/default/files/finalreport.pdf. Accessed March 7, 2022.
11. Fallout: Chernobyl and the Ecology of Disaster. An Interdisciplinary Conference. Presented April 30, 2021.
12. Murray CJL, King G, Lopez AD, et al: Armed conflict as a health problem. BMJ 324:346-349, 2002.
13. Sheather J: As Russian troops cross into Ukraine, we need to remind ourselves of the impact of war on health. BMJ 376:o499, 2022.
