Published in The Lancet Oncology
Prof Richard Sullivan: Institute of Cancer Policy (Global Oncology Group) and Conflict & Health Group, King’s College London
Dr. Mykola Zubarev: Lviv Cancer Centre, Ukraine
The invasion of Ukraine by Russia on February 24, 2022 has created a massive humanitarian crisis for Europe and degraded/destroyed a wide range of health care infrastructure, including cancer care. The impact of this conflict comes on top of near eight years of low level war between Russian backed forces in Eastern Donbas region since 2014 which had already created huge challenges for Ukraine’s health care system . Unlike many other countries around the world impacted by conflict Ukraine’s population had access to a moderately, well-developed cancer care system including radiotherapy .
Before the conflict, radiotherapy was provided throughout most of Ukraine in 55 functional cancer institutes, 52 radiotherapy centres with around 106 radiation machines, 86 being the older cobalt machines (Figure 1). This meant around 1 machine per 500,000 population, lower than the recommended 1 per 100,000. Prior to the conflict there was planning at the Ministry of Health level to modernise with transitioning from their mainly older Cobalt machines to more modern and flexible Linear Accelerators. The Ukraine association of medical physics functioned well and there were good links with Ukrainian radiotherapy communities in the Western World.
Map of distribution of external Beam radiotherapy equipment in Ukraine based on DIRAC data from the IAEA.
External beam radiotherapy in Ukraine | Ukrainian Association of Medical Physicists (uamp.org.ua)
Ukraine is a fully transitioned country with a population of nearly 44 million which saw around 162,500 new cancer patients a year. International estimates suggest radiotherapy should be utilised in an estimated 50-52% of cancer patients in Ukraine and is needed in around 40% of cancer cures . One of the critical aspects for delivering radiotherapy that makes this such a sensitive modality in conflict is the impact of vibration, the need for uninterrupted electricity supply and good ingress/egress rate internet. The use of high yield munitions either through aerial or artillery bombardment, even if not directly targeting hospitals, has disrupted and stopped such sensitive equipment. The Ukraine conflict has provided important insights into how contemporary modern conflict affects radiotherapy services, and in turn cancer services.
The conflict has also illuminated intra-Ukrainian provision of radiotherapy and also wider issues of capacity and capability in neighbouring host countries. As of writing some 13 million Ukrainian citizens are stranded in Eastern conflict areas, with limited to no radiotherapy provision, 7.7 million have become internally displaced, mostly to Western Oblasts in Ukraine and some 5.1M have crossed borders to to become refugees . By the 21st April 13 centres providing radiotherapy were under Russian occupation (either since the 2014 conflict or current invasion) and 2 centres have been damaged/destroyed and several others have equipment issues such as CT simulators not working. Centres in Western Ukraine now report an increase in total number of patients (up to over twice the number) while centres closer to hostilities report a decrease. In centres where there is constant bombing, staff and patients are living in the clinics.
Whilst radiotherapy capacity in Kyiv and Western Oblasts is currently sufficient to manage the volumes of displaced patients this may only be a temporary state of affairs. Previous experience from Middle East conflicts suggests that as conflicts become more long term and chronic the degraded of radiotherapy infrastructure due to maintenance issues is compounded by increasing patient volumes and decreasing availability of healthcare professionals as they themselves become refugees . Displaced populations, whether internal or as refugees, also quickly change the economic impact of cancer care; costs of even basic radiotherapy increase as more complex care is often required .
The situation in the surrounding host countries of Moldova, Romania, Poland and Hungary is variable. Provisions of radiotherapy for domestic populations ranges from massive under-capacity – Moldova – to broadly speaking good capacity – Poland (Table 1), although all have far less machine capacity than recommended per head of population already One of the complicating factors is that refugees are moving from country to country, for example, Romania is a staging post for many Ukrainian refugees as they move onto other places with only 25% of patients remaining in country according to IOM. This makes matching capacity to demand a moving target. For a number of discrete patient populations there are already well managed referral networks. For example radiotherapy for childhood cancers is being managed and patient distributed between many different radiotherapy centres across Europe. Likewise the Lymphoma network has been working with a wide range of centres to distribute Haemato-Oncology patients that need radiotherapy.
Radiotherapy Equipment in Ukraine and Neighbouring Countries:
Ukraine is already experiencing, despite Herculean efforts, issues even to functioning radiotherapy centres in the West; damage from increasing long range cruise missile attacks and bombers, spare part logistic chain issues (many logistic systems are now in competition with often more urgent trauma supplies), and a tired, over-stretched workforce. Patients also have difficulty travelling and accessing radiotherapy. In the West curfews and air-raids (notably in Lviv, Ivano-Frakivsk, Rivne, Zhytomyr and Khmelnytskyi) can severely curtail movement and in the conflict-impacted areas around Kyiv, Northern and Southern oblasts there remains huge threats from mines and other unexploded ordinance (very high risk across Kyv oblast), as well as constant threat of aerial attack, especially for radiotherapy centres situated near airfields and main supply routes, for example road H08 one of two main highways (other is E105) between Dnipro and Zaporizhzhia is close to Shyroke airfield and a constant target for Russian missiles.
Radiotherapy is also a direct target and has its own individual security concerns in conflict. Cyberattacks can take treatment planning and delivery off-line (as already has occurred in Ireland and New Zealand) 2 and Russia has already shown it’s willingness to utilise such tactics as part of it’s maskiroka (deception) strategy. Furthermore Ukraine has some 45 external beam and 34 brachytherapy Cobalt-60 sources. There are x5 Brachytherapy Iridium-192 sources that are now non functioning as currently transportation of radioactive materials in banned. . Whilst unlikely (low probability, high consequence) a direct high yield munition strike on one of these sources could create a serious radionucleotide contamination event.
In light of the rapid and changing conflict kinetics and the unique nature of radiotherapy as a core fixed modality in cancer care the WHO Emergency Committee for Cancer in Ukraine prompted the Global Coalition for Radiotherapy in collaboration with the ECO/ASCO Special Network to develop an Emergency Radiotherapy Task Force to gather real time information. A central source of information about treatment capacity was needed and clinical requests are already surfacing. A needs assessment in a rapidly changing situation has now been made available on an open source website and regularly updated . Gathering information during a conflict is complex and needs a number of sources that can utilised to triangulate data. Ukraine has an active medical physics association with local and national knowledge and machine manufacturers can access remote, real-time information about machine usage (providing there is internet access). Professionals have used social media to gather real-time on the ground information about work force. The radiotherapy community in Ukraine has adapted remarkably well to their new reality, with supply chains and maintenance being a priority. The international radiotherapy community has also come together in solidarity with a strong public-private relationship which has been essential for not just intelligence gathering on radiotherapy capacity and capability but also moving rapidly to address supply and maintenance issues. Ukraine will need long term support for its radiotherapy service now, and in the future. Novel solutions including consent for remote extraction of data on previous radiotherapy have been devised and will prove vital as patients continue to be displaced from their homes. Remote support for both training and treatment capacity will be important in the medium-term.
What lessons have been learnt already? The WHO and international organisations such as ECO and ASCO prioritised cancer care support early on and knew enough about the unique challenges for radiotherapy to consider this as a separate stream of work. This was vital; so often radiotherapy is overlooked, and its complex, technical challenges are often poorly understood. This central lead with experience in emergency and humanitarian responses is vital to ensure well-intended interventions are rapid, effective and coordinated; many radiotherapy centres have no time to provide information to multiple agencies.
We have also learnt from the challenges of the COVID-19 pandemic. Where patients are unable to access radiotherapy centres due to security issues the move towards shorter duration more intense treatment (hypo-fractionation) is both warranted and effective . Furthermore country’s radiotherapy capacity and recovery give us a real time guide to the status of cancer care in general, but it also provides an opportunity for technical solutions, as well as, cost effective substitute treatment to deal with cancer treatment backlogs. Radiotherapy capacity is made up of machine and IT capacity, and workforce. Additional capacity and transport are needed when patients are widely displaced across complex geographies. Before the conflict, data was available on population need and treatment machines in Ukraine, but not readily available on workforce and training. Knowledge of the workforce amongst refugees is also something we have learnt is needed in the acute phase of conflicts.
Wider lessons for health care have also been learnt; unfortunately, anything can happen in the world as we now see. Each country needs to develop emergency plans in case of a crisis; war, pandemic, climatic catastrophe, nuclear accident, etc. The first plan should describe the mechanism of action; what to do with patients, what to do with staff, how to quickly create a register of those who need help. Creating basic radiotherapy intelligence and operations plans is crucial for developed countries in contemporary conflicts. Without this humanitarian agencies (UN, WHO et al) and health care professionals did not know what to do in the first days after the war. The initial experience has also illuminated the importance of understanding how one country can help another country (take patients for radiotherapy treatment, take staff for temporary internships, etc.). While each radiation therapy department had an action plan in case of a radiation accident in their department, there were no plans in case of more global accidents. The complexity of managing patients across regions (oblasts) and borders has brought into stark relief the need for emergency SOPs that act as basic backbones for radiotherapy management and planning in conflict settings.
Long-term planning for radiotherapy also needs to start now. Prior to the conflict a programme of radiotherapy machine replacement had started with about 8 new Linacs were delivered in Ukraine; at the beginning of the war, 6 of them were put into clinical use and 2 were under installation. The purchase of this new equipment was a local initiative of the heads of clinics. However, the Government and Ministry of Health of Ukraine had recently understood the importance of modern equipment and a month before the war, an expert working group was working to organise the purchase of about 20 new Linacs which should be distributed among hospitals in Ukraine during 2022-2023. The decision to move from Cobalt to the more modern Linacs was made by the Ministry of Health of Ukraine, but not implemented. The concern now is there is a risk that this will not happen in the near future with the economic challenges around rebuilding shattered national infrastructure.
The Ukraine cancer recovery plan needs to have radiotherapy at its heart. With a technology jump, Ukraine will improve and modernise its cancer care, ensuring its sustainability for the future, and building back better. Investment is needed as well as support from government bodies, industry and professional bodies. Radiotherapy is a critical and inseparable part of comprehensive cancer care and should not be the last resource to be considered. The economic benefits of investing in radiotherapy are substantial, as well as, the benefit to patients . Ukraine has taught us that good real time comprehensive data paired with multidisciplinary professionals and industry working together, could help solve these challenges with the right targeted investment and political will.
1. Roborgh S, Coutts AP, Chellew P, Novykov V, Sullivan R. Conflict in Ukraine undermines an already challenged health system. Lancet 2022; 399(10333): 1365-7.
2. Ryzhov A, Bray F, Ferlay J, et al. Recent cancer incidence trends in Ukraine and short-term predictions to 2022. Cancer Epidemiol 2020; 65: 101663.
3. Borras JM, Lievens Y, Barton M, et al. How many new cancer patients in Europe will require radiotherapy by 2025? An ESTRO-HERO analysis. Radiother Oncol 2016; 119(1): 5-11.
4. Sahloul E, Salem R, Alrez W, et al. Cancer Care at Times of Crisis and War: The Syrian Example. Journal of Global Oncology 2016; 3(4): 338-45.
5. Abdul-Khalek RA, Guo P, Sharp F, et al. The economic burden of cancer care for Syrian refugees: a population-based modelling study. Lancet Oncol 2020; 21(5): 637-44.
6. Spencer K, Jones CM, Girdler R, et al. The impact of the COVID-19 pandemic on radiotherapy services in England, UK: a population-based study. Lancet Oncol 2021.
7. Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. The Lancet Oncology 2015; 16(10): 1153-86.