By M. Bassel Atassi, MD
Amid the ongoing conflict and large population displacement in Ukraine, patients with cancer living in areas of danger will be among the most vulnerable people affected by the war. Caring for patients with cancer in cities of armed conflict, cities under siege, cities of potential invasion, is near impossible. Caring for patients with cancer who become refugees in the neighboring countries of Ukraine has also proven to come with challenges and difficulties.
The challenges are many, including but not limited to the lack of screening opportunities, hospital closings, shortage of medication inventory and supplies, doctors who are themselves displaced, loss of higher education and training, major deficiencies in specialized medical staff including oncologists and infusion nurses, and lack of access to advanced diagnostic tools and treatment tools like interventional procedures and genetic testing.
The local Ukrainian and international medical communities have the chance to overcome many of those challenges and provide basic care for patients with cancer. Several valuable lessons can be learned from the Syrian conflict and the immense experience of the Syrian American Medical Society’s (SAMS) efforts, coordination, and contributions developing oncology centers in northern Syria.
In its 11th year, the Syrian refugee crisis remains the world’s largest refugee and displacement crisis of our time. Since the Syrian civil war officially began March 15, 2011, families have suffered under brutal conflict that has killed hundreds of thousands of people, torn the nation apart, and set back the standards of living by decades. About 6.8 million Syrians are refugees, and another 6.7 million people are displaced within Syria. This means 13.5 million Syrians in total are forcibly displaced—more than half of the country’s population. Nearly 11.1 million people in Syria need humanitarian assistance. Many Western countries and non-governmental organizations (NGOs) stood up to provide medical and humanitarian relief to the large populations in need. Cancer was not a field of medicine that received meaningful support from many agencies and relief organizations due to its extreme logistical difficulties, high expenses, and lack of specialized teams to lead such efforts. For those reasons, many stakeholders shied away from supporting cancer programs. A disheartening statement I heard from one of the international humanitarian agencies was, “We can support 500 pediatric patients with the cost of one cancer patient.”
SAMS was among the few NGOs that were able to develop and manage a step-by-step comprehensive oncology program in northern Syria, where the most vulnerable population lives. The program currently provides cancer care to a large area in northern Syria with a population of around 6 million people.
Initial steps that were taken included an in-depth analysis of the requirements of the Syrian community. Large-scale interviews with many local health care workers, administrators, surgeons, and pharmacists were conducted with the intention of constructing a detailed logistical plan. We later determined the estimated number of potential beneficiaries, and identified the needed staff with oncology degrees and appropriate experience. Furthermore, we contracted with the local oncologists who were not fleeing the war zone, and found hospital locations with basic laboratories, imaging, and surgical capabilities. Lastly, we secured the necessary sources of chemotherapy with acceptable prices, identified funding for the remaining resources, and started our own fundraising campaigns for further expansion of our mission.
The program started by focusing on the most common cancer diagnoses, and those with higher chances of being cured, especially for patients who were diagnosed in early stages. This included breast cancer, colon cancer, lymphomas, and pediatric leukemias, and later expanded to include testicular and ovarian cancers. The program we developed provided treatment, including chemotherapy, free of charge for suffering patients with a wide variety of cancer diagnoses.
The cancer center in the Idlib governorate opened in November 2018 and continues to be the main referral center for all newly diagnosed patients with cancer in northwest Syria. The center provides care to an average of 500 to 600 patients monthly, including an average of 100 new patients per month. The program is able to provide basic care to all newcomers with available services including health care provider consultations, diagnostic workups, imaging, surgery, and chemotherapy administration.
Because of the high demand for services, and using the success of the center in Idlib as a guide, SAMS started two other centers in northern Aleppo to cover a larger population of patients with cancer. The treatment plans in those centers and chemotherapeutic protocols follow the standard of care of the National Comprehensive Cancer Network (NCCN) and ASCO clinical practice guidelines. The oncologists in those centers utilize those guidelines in approaching their patients.
To solidify the clinical knowledge of the center’s staff, given that most of them are unable to have access to advances and updates in the various oncology practices, we have also established a fellowship education program in oncology and hematology with weekly online lectures, presentations, journal clubs, tumor boards, and case discussions. This program is led by board-certified oncologists from different academic and community programs in the United States.
In neighboring countries, refugees with cancer also face major issues in diagnosis and treatment, and most of them will depend on governmental support and charities to secure the cost of the expensive, complex, and complicated procedures and therapies.
Such an expansive experience in Syria can provide invaluable infrastructure logistics and a backbone to the developing Ukrainian cancer relief programs. These developed logistical details and models can expedite the overwhelming challenges the Ukrainian population will continue to face due to the tragic ongoing conflict in the region.
Dr. Atassi is a hematologist and oncologist at OSF Little Company of Mary Medical Center in Evergreen Park, IL, and a clinical associate professor of medicine at the Chicago Medical School of Rosalind Franklin University of Medicine and Science. He is chair of the Oncology Committee at the Syrian American Medical Society. Dr. Atassi invites readers to get in touch with him about this piece via email. Disclosure.
Editor’s Note: Resources for Medical Professionals and Patients Affected by the War in Ukraine
Since the February 24 invasion of Ukraine by Russian armed forces, ASCO has been actively collaborating with members in Ukraine and in the bordering countries and with a wide range of cancer organizations to support Ukrainians with cancer during the ongoing humanitarian crisis. In the first few days of the crisis, this included establishing communications with members Dr. Andriy Hrynkiv of Ukraine, Dr. Nicoleta Antone of Romania, and Dr. Jacek Jassem and Dr. Piotr Rutkowski of Poland, to understand the situation in Ukraine and among the Ukrainian refugee population. They participated in a March webinar hosted by ASCO on the challenges they and their colleagues were facing; a recording of their remarks is available.
A key part of this response has been ASCO’s partnership with the European Cancer Organisation. The ECO-ASCO Special Network has brought together more than 300 cancer organizations, governmental agencies, and others to facilitate intelligence gathering, communication, and coordination with respect to support for the Ukrainian cancer community. The network has served a key role in helping the European Commission and the World Health Organization in their efforts. Furthermore, building on their collaboration around patient information and materials, ASCO and the Society’s member volunteers are working with the American Cancer Society to provide cancer information to Ukrainian patients and care providers via telephone, email, and online chat as part of the ACS National Cancer Information System. Links to these and other Ukraine-related resources are available on the ECO-ASCO digital platform onco-help.org and on the ASCO website at asco.org/Ukraine.
While ASCO staff and volunteers are inspired by the response of those in Ukraine and the border countries to the humanitarian crisis, and are grateful for the opportunity to support their efforts, the Society is also fully aware that there are other humanitarian crises in the world affecting the critical care provided to patients with cancer. “The response to the Ukraine crisis has been tremendous,” said Doug Pyle, ASCO’s vice president of International Affairs. “We have an opportunity now to learn from this experience and apply these lessons and capabilities to help others facing similar crises in other parts of the world.”