Intended for healthcare professionals

Feature Cancer Care

Russia’s war in Ukraine is killing cancer care in both countries

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o701 (Published 23 March 2022) Cite this as: BMJ 2022;376:o701
  1. Anonymous
  1. Russia

While cancer clinics in Ukraine are being abandoned or even shelled, Russian patients, hit by sanctions and inflation, are also bracing for dark times

As the war in Ukraine unleashed chaos and upended millions of lives, many Ukrainians had to flee to the western part of the country and became refugees in Europe and beyond. Among them were patients with cancer, who faced a brutal one-two punch of severe illness and displacement. And while cancer clinics in Ukraine are being abandoned or even shelled, Russian patients across the border, hit by sanctions and inflation, also face an uncertain future for their care.

Medical care in both Russia and Ukraine, shaped in many ways by a shared Soviet past, relies largely on government funding. The Russian single payer healthcare system, known as compulsory medical insurance, is intended to cover the cost of care for all legal residents, but tariffs, set by the state, have been lagging behind actual expenditure, making some types of oncological treatments a net loss for the state run hospitals.

Ukraine’s hospitals and clinics, both public and private, are contracted by a national health service to care for patients with cancer, while a separate procurement agency oversees drug purchases. Before this war a sustained increase of their budgets allowed the system to keep pace with growing costs. And the National Cancer Institute, a research organisation tracing its roots back to the first x ray room in Kyiv at the turn of the 20th century, handled oncological research and development.

But the once close knit patient and doctor communities of Russia and Ukraine (many parts of the former USSR continue to have family in other parts, and many Ukrainian doctors have gone to work in Russia seeking better pay)—who share a common language and, in cancer, a common enemy—have been drifting apart since 2014, when Russia annexed Crimea. Anton Barchuk, an oncologist and epidemiologist at the European University at St Petersburg in Russia, says that during the eight years before the war all cross border communication was active but strictly informal. Anecdotal evidence reported in the Russian newspaper Novaya Gazeta in March indicated that Ukrainians had been smuggling drugs not available in Russia to other families in need and to Russian clinics offering discounts.1 “But there was no active interaction at the state level and at the level of associations,” confirms Vyacheslav Kopetsky, an oncologist at Ukraine’s National Cancer Institute.

What little remained now faces obliteration by the war. In the first days after the Russian attack many cancer centres in Kharkiv, Mariupol, Sumy, Chernihiv, and eastern Ukraine had to evacuate their staff as some centres were destroyed by shelling. Some had to cancel all planned treatment, while clinics in Kyiv, including the National Cancer Institute, have stopped everything but ongoing chemotherapy.

Clinics in western Ukraine have suffered no major interruptions yet but are overwhelmed by the flow of patients fleeing the east and experiencing shortages of basic drugs. Kopetsky fears that, unless the war ends soon, all oncological infrastructure in eastern Ukraine will be lost.

Amid the largest refugee crisis since the second world war, Ukrainian cancer patients are being welcomed in Europe, where they receive free treatment. But they also face utter confusion: Ukrainian and European oncologists are struggling to coordinate and route them, which leaves clinics in Poland crowded beyond capacity and centres in other countries underused.

Kopetsky says that, even with a war going on, it is up to the Ukrainian medical community to rise to the challenge and facilitate the movement of patients both within the country and beyond its borders. “So far, we haven’t done that,” he says.

Russia isolated

In recent years Russia’s rigid centralised system, with significant inequality between regions, has been undergoing a major reform that has acknowledged diagnostics and outpatient care as important parts of the equation. Patients had access to novel drugs and took part in clinical trials.23 Barchuk says, “Many pharmaceutical companies considered Russia a convenient country for research because it was quite easy to recruit patients. Clinical trials gave Russians access to modern medicines beyond the framework of conventional cancer care.”

Since the war began, foreign pharmaceutical and medical companies have so far resisted calls to join broader sanctions. Pfizer, Bayer, Sanofi, Merck,4 Novartis, and Eli Lilly have all confirmed that they will keep selling their essential products for humanitarian reasons. But supply chains and professional cooperation links are already in a shambles. On 5 March ACTO, a trade group for clinical trial organisations in Russia, called for a halt to all new projects and trial enrolment, and the European Society of Cardiology cut ties with Russian doctors.

Even without formal sanctions, as the majority of cancer drugs and supplies are imported, prices have already skyrocketed after an unprecedented collapse of the rouble. This will further exacerbate the healthcare system’s troubles in covering costs and will likely pull all resources away from cancer genetics, personalised therapy, immunobiologics, and other cutting edge treatments. Over the years Russia has been slowly stocking up on equipment for diagnostics and radiotherapy, but it is not clear how long the country can function without imported spare parts and high level maintenance.

Barchuk says, “We expect a gap in funding for cancer treatment due to financial problems. Unfortunately, there are not enough generics and biosimilars of novel drugs in Russia, and it will be very difficult to set up production in the coming years. We can anticipate drug deficits, especially for expensive medications.”

Deepening international isolation will likely erase years of work done by Barchuk and his colleagues in trying to integrate the national medical community into the global public health space. While the European Society for Medical Oncology condemns the war and “expresses profound sadness,” the European Association of Urology is going a step further and halting cooperation with partner societies from Russia and Belarus.

“Many Russian colleagues are outraged by the international community cutting ties with Russia,” says Barchuk. “But it is difficult to judge the reaction from the European Association of Urology, especially when you consider that Russian associations have not condemned the war in any way.”

Thousands of Russian doctors and nurses have signed a petition against the war5—joining scientists, artists, the IT community, and many others before it became explicitly illegal for Russians to even refer to the events in Ukraine as “war.” The prognosis for cancer patients and survivors is getting darker by the day. But, as Novaya Gazeta notes, Ukrainian mothers caring for children with cancer are still reaching out to their Russian companions in misfortune, still hoping to withstand the one-two punch together.

Footnotes

  • The reporter on this story has been anonymised for security reasons.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned, not externally peer reviewed.

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