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We defined the profile of Ukrainian cancer refugee patients.
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Women with breast cancer accounted for majority of refugee patients.
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Literature regarding the refugees' cancer care impact on the health care system is missing.
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National and local solutions introduced to improve cancer care for Refugees are shown.
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Efforts should be directed at creating procedures and engaging international societies.
Abstract
Background
On 24th of February 2022, Ukrainian cancer patients had to face a new war. Here we describe an experience of the Maria Sklodowska-Curie National Research Institute of Oncology Branch Krakow in providing cancer care for Ukrainian refugees during the initial 6 weeks of war. We present patients’ characteristic, point out the main challenges and share initiatives undertaken.
Materials and methods
For this cross-sectional analysis, we have gathered demographic and clinical data together with date of crossing the Polish-Ukrainian border for 112 Ukrainian refugees with cancer who had their first-time oncology consultation between 24th February and 8th April 2022. We have also implemented national guidelines and created local procedures, interventions and policies to manage this situation.
Results
The peak of patient inflow was the third week of War and refugees accounted for 13% of all first-time patients within that period of time. The majority of refugees were women (86%), treated radically (57%) with breast cancer (43%). Most of the patients required systemic treatment (67%). Amongst the main challenges at the time were differences in the reimbursement system, communication issues, lack of patients’ documentation or tissue samples, prolonged diagnostic or treatment interruptions, increased risk of COVID-19 infections, chemotherapy side effects, and lack of procedures. Legal, procedural and organizational steps implemented at the local and national level were described.
Conclusions
The Russian invasion on Ukraine forced an unexpectedly high number of Ukrainian cancer patients to seek help abroad, leading to the straining of the health care system in Poland.
With more than 43 million inhabitants, Ukraine is one of the biggest European countries in terms of size and population. It belongs to the group of lower middle-income countries [
In 2018, 170,000 new cases and almost 100,000 cancer-related deaths were reported in Ukraine, with a predicted significant increase in cancer incidence of almost 18% from 2012 to 2022 [
], allowing patients with suspicion of cancer (or cancer recurrence) to undergo prompt imaging procedures, biopsy, and start the treatment within a required period of time in order to avoid delays and to improve cancer prognosis [
]. Currently, the National Cancer Strategy 2020–2030 that promotes the development of the National Oncological Network is still at its implementation stage. It divides the cancer care suppliers into three levels of reference [
]. In Poland, modern oncological therapies financed by the National Health Fund are organized by the Ministry of Health into medication programs. Each patient qualified for therapy is included according to special rules of the medication program [
Overview and analysis of the cost of drug programs in Poland: public payer expenditures and coverage of cancer and non-neoplastic diseases related drug therapies from 2015-2018 years.
On 24th February, Ukraine was attacked by Russia, which forced millions of Ukrainian citizens, mainly women, children and the disabled, to leave their country, and to opt for Poland as their first-choice direction. During the first 6 weeks of war, almost 3 million people crossed the Ukrainian-Polish border, with a peak on 6th March. Most of them stayed in Poland [
]. The Polish population constitutes 85% of that of Ukraine, but the cancer care system is organized differently, with private sector being only a margin, and public funds covering the cost of treatment [
The war has in many ways influenced the treatment of Ukrainian cancer patients. It has not only disrupted and delayed the diagnostic process, suspended systemic treatment or other forms of cancer treatment (radiotherapy, surgery), but has also withdrawn Ukrainian sites from clinical trials [
While facing the challenging first weeks of the 2022 war in Ukraine, the oncologists in Poland were not supported by the existing literature that would help predicting the cancer patients’ profile or the timing of their arrival. The potential challenges were not defined and proper procedures were lacking. Some of the questions the health care experts faced at the time were: What are the needs of Ukrainian oncology refugee patients? Would they decide to move to another country? How to manage the risk of a prolonged break in their diagnostic or treatment period? How many patients would leave Ukraine? When can the peak of relocation be expected? We hypothesized that the inflow of Ukrainian refugee patients might start a few weeks after the war began as patients would be afraid of interrupting the treatment. Looking at the available literature for the Middle East population, we supposed that men with cancer would migrate to seek proper cancer care at least as commonly as women. We expected communication issues and reimbursement of medications to be the main challenges.
The aim of this study was:
(1)
to explore the profile of cancer patients among the refugees; the time of the decision to flee the war-torn country and transfer cancer treatment to another country in the case of Ukrainian cancer patients;
(2)
to define challenges connected with the unexpected inflow of cancer refugee patients from one European country to another;
(3)
to share what local solutions were introduced to manage the growing number of refugees requiring oncological support.
2. Materials and methods
2.1 Study design and data collection
For this cross-sectional analysis, we have gathered data for 112 Ukrainian Refugees with cancer who had their first-time oncology consultation in the Maria Sklodowska-Curie National Research Institute of Oncology Branch Krakow during the first 6 weeks of the war (between the 24th February and 8th April 2022). Patients were eligible to enter the study if they; (1) had Ukrainian citizenship, (2) crossed the Ukrainian-Polish border on 24th of February or later, (3) had cancer or suspicion of cancer, (4) had their first-time consultation visit between 24th Feb and 8th March 2022. Data were gathered from patients' clinical records and anonymized. The information acquired included: sex, age, type of malignancy, type of treatment (palliative vs radical), date of the first consultation, presence of cancer diagnosis (yes vs no), treatment required (yes vs no), type of treatment required (surgery vs radiotherapy vs systemic treatment), and type of systemic treatment required (chemotherapy vs hormonal therapy vs targeted therapy including immunotherapy). Additionally, the following data were gathered: time from crossing the border to first consultation (collected in order to examine if the patient is a refugee and so is eligible for free cancer care), previous consultations in other oncology units in Poland (yes vs no, yes when the patient had already enrolled on the ‘fast-track oncology pathway’ in another oncology unit in Poland).
2.2 Statistical analysis
Elements of descriptive statistics were used to determine the main features which characterized the population: median, range, quartile, mean, standard deviation and percentage distribution. The manuscript presents the challenges posed by the treatment of a new group of patients (Ukrainian refugees). Due to this descriptive character of manuscript, only descriptive statistics were used for the estimation of basic parameters. The statistical analysis was carried out using the STATISTICA v13 software.
2.3 Ethical considerations
The study was conducted in accordance with the ethical standards laid down in the 1964 Helsinki Declaration and its later amendments. The project of this study was approved by the Ethical Committee (decision no OIL/KBL/18/2022). All patients gave their written, informed consent to use the data for scientific and publishing purposes. The consent was obtained with the presence of an interpreter and using translated forms (Ukrainian or Russian when required).
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
3. Results
From 24th February 2022 to 8th April 2022, 112 refugees from Ukraine reported to the National Research Institute of Oncology Branch Krakow, constituting13% in relation to the total number (967) of all patients who had their first consultation during that period of time. We had no additional medical personnel to provide care for this group of patients. Communication difficulties meant that refugee patients needed longer contact with doctors and nurses. This additionally increased the workload on the medical staff of our facility. The youngest patient was 19, while the oldest was 85; the median age was 52.5 years (Table 1).
Table 1Demographic data and treatment information for 112 Ukrainian patients – refugees who were admitted to National Research Institute of Oncology Branch Krakow between 24th February and 8th April 2022.
The majority were women (87% F vs 13% M). 57% of patients were qualified for radical treatment, while 35% required palliative therapy (Table 1). Admission to the Krakow Oncology Centre peaked in the third week (35%) of the war (Fig. 1), with the maximum number of 17 people being seen in the clinic on the 18th day of the defined period. 46% of patients were consulted in the National Research Institute of Oncology Branch Krakow in the first week after crossing the Ukrainian-Polish border (Fig. 2).
Fig. 1Time from first day of 2022 war in Ukraine to first consultation in Krakow Cancer Centre.
The most frequent diagnosis was breast cancer (43%), followed by gynecological tumours (16%), colorectal cancer (11%), less often lung cancer (7%), hematological tumours (5%), melanoma (3%), larynx (2%), sarcomas (2%) and thyroid cancer (1%). The neoplastic disease diagnosis was required in 8% of all patients who came to Krakow Cancer Centre during the defined period (Fig. 3). Challenges connected to providing cancer care for refugees are presented on Fig. 4.
Fig. 4Challenges connected with providing cancer care for refugees (presented after subjective authors' assessment from more to less important topics).
The vast majority of patients required continued oncological treatment (87.5%). Most of the patients required systemic treatment (68%): chemotherapy (33%), hormone therapy (25%), targeted therapy (16%), and immunotherapy (9.8%). Some patients required the use of two types of systemic treatment simultaneously (for example immunotherapy and hormone therapy or chemotherapy). 16% of patients were included in therapy in special medication programs financed by the National Health Fund (financing according to special rules). Surgical treatment and radiotherapy were required by 9.8% and 8% of patients, respectively (Table 1).
Local and country activities were initiated in order to provide care for a new group of cancer patients. The timeframes for Krakow Cancer Centre were as seen in Table 2.
Table 2Timeframes for actions introduced to manage the oncological care of Ukrainian refugee cancer patients [
First patient-refugee consulted in Krakow Cancer Centre
1st March 2022
Phone number (local initiative of Maria Sklodowska-Curie National Research Institute of Oncology Branch Krakow, Warszawa and Gliwice)
3rd March 2022
Information in Ukrainian on Krakow Cancer Centre Facebook informing about consultations for Ukrainian Refugees
9th March 2022
National phone number created for Ukrainian refugee cancer patients That information was published on Facebook on 11th March 2022
12th March 2022
National legislation passed about free treatment for Ukrainian refugees. Since then patients have enjoyed the same rights as Polish cancer patients (also in terms of treatment reimbursement). That information was published on Facebook on 17th March 2022.
13th March 2022
Interpreter (specialist in internal medicine) hired at Krakow Cancer Centre
The study outcomes did not support the hypotheses about the patient profile and migration time. The patient inflow peak was observed as early as in the third week of the war. The Refugees were mainly women treated radically for breast cancer and gynaecological malignancies. As expected, communication issues and reimbursement issues were identified, but legislation (on national level) and hiring an interpreter helped solving that problem.
The 24th of February brought the need to introduce prompt changes into oncology care in Poland. At that time there was no information about what and when to expect. There were no relevant scientific data to guide our next steps and the literature was scarce, limited to the Middle East humanitarian crisis [
Our data (Fig. 1, Fig. 2) show that patients waited in Ukraine some time (about 2 weeks after the war started), probably to assess the situation. When it was clear that war would continue, they decided to seek treatment in Poland. Probably due to the presence of large Ukrainian community living in Poland before the war and due to using social media to distribute Polish local and national initiatives to provide cancer care for Ukrainian patients (e.g. phone numbers with medical information in Ukrainian, see Table 2) patients almost immediately came forward to oncology centres.
Since 13th of March, patients were consulted in the presence of an interpreter. Neither Russian nor Ukrainian are popular languages in the Polish population [
]. The average time for first-time consultation was necessarily doubled for Refugees in comparison to the non-refugee patient. That was especially challenging during the first week of March 2022 when no interpreter with medical background was available, no documentation had official translations, and patients were lost in terms of where and how to seek help. The issue was also the quality of translated documentation as translations were often done by non-medics. We decided to double the planned time for first-time visits for patients from Ukraine (limiting at the same time the number of possible patient consultations) and admit Ukrainian refugees outside of the waiting queue as they appeared in the outpatient department personally and actively searched for immediate consultation (before the national legislation was announced, initially during the first 2–3 weeks). During that period, no additional staff members were hired, and therefore, additional duties resulted in staff overtime (including all types of personnel).
The reimbursement system in Ukraine is different from the Polish one, as the former also allows the patients co-paying their treatment or receiving private care. That is not an option in national cancer centres in Poland. For instance, in Ukraine, bevacizumab was initiated together with first-line FOLFOX in patients with metastatic colorectal cancer. In Poland, bevacizumab was reimbursed as a first-line treatment in combination with FOLFIRI, and as a second-line treatment in combination with FOLFOX. The other issue was that Ukrainian patients who had paid for private cancer treatment outside of Ukraine before the war could obtain refugee status and free cancer treatment in Poland by crossing the Polish-Ukrainian border after 24th of February [
]. Some patients decided to do it in order to receive reimbursed treatment in Poland. We had a few cases of patients with Turkish or Italian documentation who wished to initiate or continue the treatment with checkpoint inhibitors or other expensive therapies in Poland. All of these patients received that treatment free of charge in the Krakow Cancer Centre as that was allowed by legislation [
]. Some of these patients (until then living outside of Ukraine or Poland) moved to Poland, some continued living abroad and travelled to our centre only for the infusion period. On some occasions, patients accustomed to private health care system expressed their dissatisfaction with treatment time initiation and the waiting time for the consultation. At the same time, half of the patients were consulted within the first week after crossing the border. Around 10% of patients consulted for the first time in our centre had already been consulted and were offered treatment in another oncology unit in Poland. The ‘fast-track oncology pathway’ for cancer patients in Poland (that allows e.g. faster diagnostic procedures and treatment initiation) when opened in one hospital cannot be opened again in another place, and therefore, it was easy to see who had already searched for help elsewhere. These patients admitted they wanted to get a second opinion or counted on faster treatment initiation. That shows that patients came prepared and got support in Poland with organizing their hospital visits.
No tissue (formalin-fixed paraffin-embedded tissue) was available for the majority of Ukrainian refugees e.g. for mutations and/or rearrangements diagnosis in non-small cell lung cancer. That resulted in treatment delay due to prolonged diagnostic procedures (biopsy, genetic testing) or decisions about suboptimal treatment (e.g. there is no reimbursement of checkpoint inhibitors in NSCLC without exclusion of certain mutations and gene rearrangements). That issue is also an obstacle when offering participation in clinical trials. None of the refugee patients were offered participation in a clinical trial. In fact, there are studies showing that refugees all over the world receive suboptimal treatment even if treated in reference cancer centres [
]. In about one-third of cases when formalin-fixed paraffin-embedded tissues were available, the tissue had to be embedded in paraffin again, e.g. due to transport damage or blocks that did not fit the devices in laboratories.
Lack of documentation was especially dangerous if no histopathology was known. However, that situation was uncommon. We accepted all types of documents where histopathology was described (also if that was a discharged chart from systemic treatment). Lack of original documentation was a challenge also for radiotherapeutics as no irradiation dose or region could be recalled.
The majority of patients lived in Krakow while continuing the treatment here. Some faced logistic issues with transportation or housing. As they commonly shared one room with others in dormitories, the risk of infection was increased for them. The percentage of COVID-19 vaccinated patients was also lower than in the case of Polish population and so their inoculation against COVID-19 had to be organized. On 24th of February, only 37% of Ukrainian population received at least two doses of vaccination against COVID-19 [
]. Some patients decided to go back to Ukraine between the treatment cycles. The treatment of therapy side effects was obviously unsatisfactory and these patients required other types of internal medical support while being hospitalized in the Krakow Cancer Centre. For the first 2.5 weeks, the patients had to pay 100% for the supportive treatment bought in pharmacies (e.g. antiemetic treatment, low-molecular-weight heparins) that resulted in abandoning these therapies and a higher risk of developing side effects.
The time for imagining testing was increased during that time (however, precise data were not gathered) due to the large number of patients coming without scans, the average time for systemic treatment initiation was increased from 3 to 5 weeks on average during that period.
Caring for refugee patients involves additional material and non-material costs. Carrying out a detailed economic analysis is beyond the competence of the authors. On the other hand, non-material support packages are a very important aspect of care for refugee patients. This group of patients requires special care and a lot of involvement of medical personnel. Very often it is necessary to provide psychological, social and legal support to refugees treated in Poland. The lack of complete and translated medical documentation into Polish and the language barrier additionally extends the medical visit and increases the overwork of the medical personnel. In order to plan oncological therapy, it is necessary to perform additional medical procedures to fill in the missing information. This increases the material and non-material costs of caring for refugee patients. The language barrier does not allow for smooth telecommunication and in this way informing refugee patients, for example about the results of examinations and planned visits, etc. It is necessary to contact the medical staff directly and often with the involvement of an interpreter. Communication difficulties result not only from the language barrier, but also from the lack of willingness to communicate due to the trauma associated with the state of war. Thus, caring for refugee patients additionally engages the medical staff emotionally and is a psychological burden.
Apart from the obvious increased financial needs for oncology treatment and consultations, the financial impact was also higher due to the need to hire an interpreter and increased need for COVID-19 testing for unvaccinated patients. Polish health care system was already underfunded and needed a rapid recovery plan even before the war [
The majority of patients were women (breast cancer and gynaecological malignancies), treated radically. There might be a few reasons explaining that phenomenon. First of all, the majority of refugees were women and children as men had remained in the country to do military service. Additionally, recent data show that women with breast cancer treated radically are a group of patients that actively seek alternative and complementary therapies. That group can also be most commonly willing to seek any type of help during cancer treatment [
]. Our results are not aligned with the data obtained for the Afghan population treated in Pakistan. In the case of the long Middle East conflict, the most numerous groups were men with gastrointestinal malignancies. It can be due to the conflict intensity, cultural differences as well as cancer types distribution dissimilarities [
]. Therefore, all these factors should be taken into account when predicting what group of oncology patients would become refugees when conflicts start.
The majority of patients seen in our centre required systemic treatment. The percentage of patients receiving targeted treatment would probably be higher if the results of genetic testing of tumour samples were available, as described above. Refugees’ treatment in most cases is not a one-time procedure and requires repeated efforts in providing systemic treatment and proper follow-up as supported by our data.
The reason for not receiving cancer treatment for 12.5% of patients who were consulted were: poor performance status due to cancer progression (these patients were offered hospice/house hospice care) or follow-up period after the treatment received in Ukraine (these patients were offered imaging studies/tumour marker testing following guidelines for each cancer follow-up).
The peak for the number of consultations was in the third week of war, which was unpredictably fast. Unfortunately, we were only partially prepared for that number of patients, with very limited literature data available in terms of what to expect [
]. Overall, in such a situation all actions should be initiated immediately. We hope that our experience may help other colleagues all over the world to understand how such process could look like, how quickly the situation changes, and what issues can be met. The peak of cancer patients followed the peak of all refugees crossing the border in March 2022 (with only a few days’ delay, so the average time our patients had from crossing the border to first-time visit).
4.1 Study limitations
This is a single-centre study and may not reflect the situation in all cancer sites in Poland. However, the goal of this study was to explore the timepoint after the conflict onset we may expect the greatest patients’ inflow and the profile of patients that decide to seek help in terms of cancer care. These results may shed a light on these topics. On the other hand, the National Oncology Institute in Krakow, as a centre with the third level of reference, is the closest to the Polish-Ukrainian border. For this reason, our data are unique.
The data gathered may be biased through incorrect translation and interpretation as communication issue was mentioned numerous times.
We are a reference cancer centre, and so it can be assumed that patients will be directed more willingly to such a unit than to local chemotherapy wards. Additionally, although we provide comprehensive care for almost all types of cancer patients, we do not diagnose and treat thyroid cancer or other endocrinological malignancies. These patients might have been directed to another specialist centre in Krakow.
5. Conclusions
The conclusions that can be drawn from the study are:
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Patients who decide to actively seek help abroad are women and during radical treatment.
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A large number of patients can be expected in a very short period of time (13% increase in patient number for first-time consultations) if the population of potential refugees is comparable to the population of the destination country.
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Hiring interpreters for translations during consultations, hospital documentation and patients’ documentation translations should be organized promptly. Using translated, standardized forms for history collections may be useful.
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There is an urgent need for legislation covering the financial and organizational issues.
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The financial burden results not only from the increased procedure number, but also from how demanding these procedures are.
Our suggestions following the study include:
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A plan should be drawn for patients who will return to Ukraine after the conflict ends and who wish to continue the treatment, but cannot afford to pay for it in Ukraine.
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Oncologists from high-income countries have their efforts focused on improving high standards of cancer treatment with increasing the access to new, most effective therapies. We suggest that these efforts should be partially directed at decreasing the huge gap between options available for different populations of cancer patients, including cancer refugee patients.
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There is a need for involving international society in terms of financial support for cancer refugees, but also for institutions offering cancer care.
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The presented data can reflect a potential situation in any other European countries in case of unexpected military conflict and no other currently available literature addresses this topic.
Authors’ contributions
Study design and study concept: MP, AGW. Data collection: MP, AGW, GS, TZ, JL, ASZ, TK, EP. Data analysis and interpretation: MP, AGW, AA, AMM. Statistical analysis: AA, AGW. Manuscript writing and editing: MP, AGW. Manuscript critical revision: MP, AGW, SK, JR, MZ. All authors read and approved the final version of the manuscript. The corresponding author MP had the final responsibility to submit the article.
Conflict of interest statement
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
Overview and analysis of the cost of drug programs in Poland: public payer expenditures and coverage of cancer and non-neoplastic diseases related drug therapies from 2015-2018 years.
We would like to point out the current situation of Ukrainian patients with cancer , who are refugees of war in Poland, as a comment, the report of patients seen in Maria Sklodowska-Curie National Research Institute of Oncology, Krakow branch during the first 6 weeks, presented in the current issue of European Journal of Cancer. During first 3 months of war more than 3.5 million people from Ukraine crossed Polish border (more than 75% of total number of refugees) and about 2 millions of them decided to stay in our country and more than 1 million received citizen identification number.
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