Just days after Russia invaded Ukraine on February 24, ASCO, together with its partners 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. Since then, ASCO, along with the World Health Organization (WHO), the European Union Commission, the newly formed ASCO–European Cancer Organization (ECO) Ukraine Steering Committee, and the ECO Board launched a Special Network (asco.org/Ukraine; www.europeancancer.org/topic-networks/20:impact-war-in-ukraine-on-cancer.html), a centralized resource center for Ukrainian patients with cancer and for refugees fleeing to bordering countries, to help them continue receiving cancer care. (See “How ASCO, ECO, and WHO Are Marshaling Resources to Provide Care for Ukrainian Civilians and Refugees With Cancer” in the April 25 issue of The ASCO Post.)
Although the exact number of patients receiving cancer care before the war began—and how many have fled since its start—is unknown, data showed in 2020, Ukraine had a high cancer burden of nearly 163,000 new cases of cancer and more than 84,000 deaths from the disease.1 The country also has one of the highest childhood cancer mortality rates globally, and it is estimated that at the start of the war, more than 1,500 children with cancer were receiving treatment.2 According to WHO, hundreds of children with cancer are now seeking care in other countries, but interruptions in treatment, increased levels of stress caused by war and relocation, and the risk of infection threaten their survival.3
Containing Disease Epidemics
Prior to the invasion, Ukraine was also struggling to contain epidemics of other life-threatening diseases, including HIV and tuberculosis. With health systems disrupted or destroyed—as of late March, there have been 82 attacks on health-care facilities, resulting in at least 72 deaths and 43 injuries, including health-care professionals and patients4—vaccinations for preventable childhood infections, including polio and measles, as well as COVID-19, already at exceedingly low rates before the fighting began, are now increasingly difficult to administer.
With more than 4 million Ukrainian refugees seeking protection and support across the region,5 sparking Europe’s largest refugee crisis since World War II, fears are mounting that health-care systems in neighboring countries are quickly becoming overwhelmed, limiting access to essential health-care services for patients with cancer. In addition, the cascading effects of poor shelter and overcrowded living conditions, as well as nutritional stress and exposure to cold weather, will result in outbreaks of a variety of life-threatening infections, including COVID-19, measles, polio, influenza, and diarrhea.6
The growing humanitarian crisis in Ukraine and across Eastern Europe is adding to the already tragic consequences of war and conflict across the world. According to the United Nations High Commissioner for Refugees (UNHCR), as of mid-2021, it is estimated that a staggering 84 million people worldwide were forcibly displaced due to conflict, persecution, generalized violence, or human rights violations.7
Paul B. Spiegel, MD, MPH
To learn more about how the displacement of people impacts their ability to receive cancer care and other essential health-care services, on the eve of the Russian invasion of Ukraine, The ASCO Post talked with Paul B. Spiegel, MD, MPH, Director, Center for Humanitarian Health and Director of the Center for Global Health at Johns Hopkins Bloomberg School of Public Health, and former Deputy Director of the Division of Programme Support and Management of the UNHCR.
Please talk about how war and conflicts further complicate accessing care for patients with cancer.
We need to differentiate between cancer care that is available in low- and middle-income countries compared with high-income countries. In the former, some aspects of cancer care, including cancer screenings, are not implemented consistently, and a tremendous number of cancers may be missed as a result.
Furthermore, if people in any country can be diagnosed with cancer and receive treatment, the disruption in care caused by war and conflict can be devastating. It is what we are seeing now in Ukraine. Refugees are coming across the border into neighboring countries in many cases without current medical records, so maintaining continuity of cancer care is difficult. It is also what we have witnessed in past conflicts in places like Syria, when millions of Syrian refugees poured into Turkey, Lebanon, and Jordan seeking asylum. The resources of those countries were overwhelmed, especially their public health-care resources for diseases like cancer.
In some of the refugee camps I’ve visited in Africa, particularly in sub-Saharan Africa, there is little to no possibility in getting treated for cancer, so people, sadly, often die with limited palliative care.
I recently returned from Afghanistan, which is going through a difficult time. In many remote areas of the country, cancer treatment was not always available, but in the regional capitals of the country, as well as Kabul, it was possible to receive treatment for cancer. But all that changed on August 15, 2021, when the Taliban took control of the country, and Western powers suspended foreign aid to Afghanistan to prevent any money from going into Taliban hands.
Now, even in Kabul, there are few functioning public hospitals due to sanctions, and all foreign aid to the government has stopped. In countries like Afghanistan, where conflict has waxed and waned, there is much instability, and it is difficult to provide cancer treatment in a stable manner.
Overcoming the Triple Threats of Cancer,
Corruption, and Workforce Shortages
War is not the only reason cancer care is disrupted for patients. Medical care is also often delayed or nonexistent in cities like Basra, Iraq, which are rife with corruption, and money earmarked for drug and imaging procurement is stolen.8 And in countries like Turkey, many physicians are leaving because of long hours, increasing violence, and low pay.9 Please talk about how these factors also jeopardize care for patients with cancer.
These situations are very difficult to resolve. In crisis situations, it is often the upper- or middle-class populations that can afford to leave, and many of those people are health-care workers. This is certainly the case in Afghanistan, where many health-care providers were able to flee the country.
Another complication is, in certain countries, female health-care providers are not allowed to work. This time in Afghanistan, the Taliban is encouraging female health-care providers to go to work. However, with sanctions in place, they are not getting paid, and there are no medicines for treatment.
Implementing Resource-Stratified Guidelines to Provide Care for Refugees
Although international agencies such as the United Nations provide some financial support for the care of refugees with cancer, these patients are often considered to have a very poor prognosis and are too costly to treat, thus given low priority. However, many patients with cancer do not have a poor prognosis, and treatment can be less costly when resource-stratified guidelines are applied to manage their care.10 How can the implementation of resource-stratified guidelines help provide early diagnosis and treatment for refugees with cancer?
Resource-stratified guidelines apply the principle of countries helping the largest amount of people with the resources they have. We used this principle in Lebanon and Jordan during the influx of Syrian refugees into these countries. When patients require expensive and complicated care, the UNHCR’s Exceptional Care Committee (ECC) makes the decision on whether to fund the treatment, which is usually based on a patient’s prognosis.
Another way to approach the problem—although to my knowledge, it has not been put in place yet—is to look at treating refugee patients with previous-generation treatment protocols that are less expensive but generally not as effective as the latest, more expensive treatment protocols. This scenario sets up massive ethical concerns, because you could have the country’s nationals getting the more expensive protocol and the refugees or undocumented migrant populations getting the less expensive, less effective medicines. However, from a public health perspective, you could save more lives by using a slightly less effective and less expensive protocol. Ethically, it is fraught with problems, which is likely why this approach has not yet been implemented.
Championing Universal Health Care
What can be done in wealthier countries to improve access to care for patients with low income and for undocumented immigrants with cancer?
The number-one solution is to prevent cancer and to make sure that cancer prevention strategies are free for everyone. America’s health-care system is very different from the health systems in most other high-income countries, where there is a basic level of care for everyone. So, America is unique in a negative way, because not everyone has access to health care, which many of us would say is a basic right.
If people do not have health insurance and must pay out-of-pocket for their care, they are likely not going to get preventive cancer screenings, and the cost of their care if they do have cancer will be higher. Providing universal health care for everyone would encourage sustainable, preventive health practices, reducing both the number of cancer cases and medical costs.
DISCLOSURE: Dr. Spiegel reported no conflicts of interest.
1. International Agency for Research on Cancer: Globocan 2020: Ukraine. Available at https://gco.iarc.fr/today/data/factsheets/populations/804-ukraine-fact-sheets.pdf. Accessed May 3, 2022.
2. 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 May 3, 2022.
3. World Health Organization: The impacts of war on children with cancer—ensuring continuation of care for those whose lives depend on it. Available at www.euro.who.int/en/health-topics/health-emergencies/ukraine-emergency/news/news/2022/03/the-impacts-of-war-on-children-with-cancer-ensuring-continuation-of-care-for-those-whose-lives-depend-on-it. Accessed May 3, 2022.
4. World Health Organization: Surveillance System for Attacks on Health Care (SSA). Available at https://extranet.who.int/ssa/Index.aspx. Accessed May 3, 2022.
5. United Nations High Commissioner for Refugees: Operational Data Portal: Ukraine Refugee Situation. Available at https://data2.unhcr.org/en/situations/ukraine. Accessed May 3, 2022.
6. World Health Organization: Ukraine Crisis, Public Health Situation Analysis: Refugee-hosting Countries. March 17, 2022. Available at www.euro.who.int/en/health-topics/health-emergencies/ukraine-emergency/publications-and-technical-guidance/ukraine-crisis.-public-health-situation-analysis-refugee-hosting-countries,-17-march-2022. Accessed May 3, 2022.
7. The UN Refugee Agency: Refugee Data Finder: Available at www.unhcr.org/refugee-statistics/. Accessed May 3, 2022.
8. Loveluck L, Salim M: The U.S. built a hospital for Iraqi children with cancer. Corruption ravaged it. The Washington Post, December 16, 2021. Available at www.washingtonpost.com/world/2021/12/16/iraq-hospital-corruption/. Accessed May 3, 2022.
9. Gall C: Turkey’s doctors are leaving, the latest casualty of spiraling inflation. The New York Times, February 8, 2022. Available at www.nytimes.com/2022/02/07/world/asia/turkey-inflation-doctors.html. Accessed May 3, 2022.
10. El Saghir NS, Soto Pérez de Celis E, Fares JE, et al: Cancer care for refugees and displaced populations: Middle East conflicts and global natural disasters. Am Soc Clin Oncol Educ Book 38:433-440, 2018.