Challenges and Solutions: Colorectal Cancer in Ukraine

In the inaugural event of the Global Cancer Movement, initiated by OncoDaily, Dr. Nelya Melnitchouk, Assistant Professor at Harvard Medical School and founder of the Global Medical Knowledge Alliance, sheds light on the immense challenges and innovative solutions in colorectal cancer care in Ukraine amidst the ongoing war.

Thank you for such a kind introduction, so I’ll be talking about challenges and solutions in colorectal cancer care in Ukraine. And yes, I am assistant professor at Harvard Medical School, also founder of nonprofit Global Medical Knowledge Alliance with the mission to improve cancer care in Ukraine and globally. I have no disclosures and a little bit to start about Ukraine.

So it’s a country in the center of Europe with population of 44 million. It’s a democracy, but in 2014 we had invasion of part of the Ukraine by Russia and full-scale invasion in February 22 has started and continues until this day. We have a large number of people who are displaced both internally and externally, tens of thousands of civilians and soldiers have died.

Russia at this point occupies 20% of Ukrainian land and 40% of Ukrainian electrical infrastructure is damaged. And as I am speaking right now, some of my teammates who are working very closely with me on cancer care in Ukraine in bomb shelters, because there is another massive attack on Ukraine just right now. But moving on a little bit into colorectal cancer care in Ukraine.

So colorectal cancer in Ukraine is most common cancer cumulatively in both sexes. In 2022, we had 20,000 of new cases diagnosed, 34% of patients with colon cancer and 27% of patients with rectal cancer die within a year of diagnosis. That was our own work published in 2018.

Ukraine has no population-based screening. And in 2018, opportunistic screening was encouraged by Ministry of Health Order 504. And this August, August of 2024, National Cancer Control Plan was established, which encourages screening as well.

I’ll share with you some of our work done in Ukraine on colorectal cancer and cancer in general. And you’ll have opportunity to ask questions at the end. So we have, so one of the kind of interests, both my academic interest and Ukrainian stakeholder interest was, is colorectal cancer in Ukraine is screening cost effective?

So we designed a Markov model where we compared colonoscopy, FOBT, FET, sigmoidoscopy with FOBT and no screening modality and found that colorectal cancer in Ukraine, colorectal cancer screening in Ukraine is actually cost saving. And colonoscopy every 10 years is superior to other modalities, but other modalities were also cost saving. We have also looked at regional disparities and national trends in incidence management and mortality.

And we can see that colorectal cancer is on the rise. The data is only until 2014. That’s the most reliable data that we have.

And some disparity both in incidence, but also in access to specialized treatment rate between the Ukrainian regions. We also looked in trends in solid tumor incidence in Ukraine 30 years after Chernobyl, and we did not see any correlation of Chernobyl to incidence of colorectal cancer in Ukraine. And one of the studies that we have done is a mixed method study where we try to see what the actual treatment quality is like in Ukraine.

This is a study from one region of Ukraine, western part of Ukraine, where we found that large number of patients in Ukraine did not have a complete staging before the treatment. Very varied use of both adjuvant and neoadjuvant chemotherapy. Significant issues with guideline-concordant care and lack of resources were the biggest stated reason for the issues with guideline-concordant care.

This is another study that we’ve done to investigate a little bit more barriers to evidence-based colorectal cancer care in Ukraine. And again, the issues with resources came up. But another thing that came up from this study that a large number of Ukrainian physicians and healthcare professionals were mentioning that English language proficiency has been a big issue for them, and access to high-quality evidence-based literature as a result of both paywall and English language proficiency was an issue.

There were issues with knowledge and obviously health system barriers. And this is just another study where we were trying to investigate a little bit more what the colonoscopy needs would be to implement colorectal cancer screening in Ukraine. And as we can imagine, it ranges from modality, but ranges from 6,600 for FOBT to 76,000 for colonoscopy.

And in summary, what are the big issues for colorectal cancer care in Ukraine? So we do have late stage of disease and diagnosis, and at this point, no screening. Very limited adherence to guideline-concordant care, and that varies across the regions in Ukraine.

The other thing is that we have no mechanism for quality and safety concerns. Lack of resources continues being an issue, and English language proficiency and access to high-quality medical literature. For medical personnel has been an issue that has been brought up many, many times.

So before February 2022, we worked very closely with Ukrainian stakeholders to work on items that are needed to establish colorectal cancer screening program. And that’s why we did the Markov modeling and modeling on the numbers needed for the colonoscopy. We started collaboration with Ukrainian National Cancer Institute, and because of that, we established organization Global Medical Knowledge Alliance.

Here’s the website where we provide educational materials that are open-source, high-quality, evidence-based, practical. They are written by experts in the field, and we are translating them into Ukrainian language. Although we’re doing that for Ukraine, as I am Ukrainian and have been doing majority of my work in Ukraine.

But all of our material is actually available in English language for all as well. We just don’t have enough resources to try to disseminate it throughout the world. But if you go on the website, you’ll find that.

And yeah, as I mentioned, it’s present on our online platform, both in English and Ukrainian. And just since we have a wide audience here, if there is a need to translate those resources into a different language, we are open to that. And we would be actually very happy to collaborate with you.

And so what is the impact of the war on cancer care, not specifically colorectal cancer, but cancer care in general? We know that a large number of Ukrainian health care facilities have been destroyed and some oncology centers as well. Radiation facilities are targeted, treatments are being disrupted, and we have limited access to essential cancer medications, including chemotherapy.

There is also indirect impact. Large number of patients are displaced and they are facing delays in diagnosis and treatment. Interrupted medical education, so it affects oncology training as well.

And then we’re also dealing with war crimes against health care professionals and patients. So we can divide those difficulties into kind of three buckets. So resource limitations, shortage of medical supplies and essential drugs, limited adherence to evidence-based guidelines due to resource constraints at this point.

Large number of operational difficulties. Coordination of care is difficult. Care itself is disrupted by air sirens, power outages and facility damages.

And then also what’s really what makes it really hard for the system, that real-time patient data and treatment tracking are very challenging. There is no data like that. There are some adaptations that Ukrainian community is doing.

There are mobile health units, patients can have remote consultations and very large collaborative efforts with international organizations to fix medical supply chains underway. And some have been established. What we have been doing to support Ukrainian cancer care at this point, we are continuing providing educational support for Ukrainian health care professionals.

We also established observership programs for those oncology professionals within Harvard system and US in general. We have supported development of cancer care guideline in a time of war and continue with research and analytics and collaborating very closely with Ministry of Health, National Cancer Institute and international NGOs. One thing that we’ve done most recently, it’s the cancer capacity mapping surveys.

We’ve done that among the patients on social media, but and in person for cancer centers. And 60% of those patients report prolonged wait time for diagnostic test. 61% report supplemental out-of-pocket payments to expedite the imaging.

The good news is 60% of patients were able to start their treatment within one month. 25% report delays in initiating treatment due to war and 11% report treatment interruptions. But if you’re closer to the front lines, if you’re in Harkiv, that’s the number moves to 23% and 30% of patients report need to cover cost of the instrument supplies or the medications.

There’s also continued systemic therapy shortages across the Ukraine. Access to immunotherapy and targeted treatments remain very, very limited. Large number of patients do pay out-of-pocket for their cancer treatment.

And a lot of patients moved within Ukraine and abroad to be able to receive cancer care. And less is the displacement just due to war. And total number of cancer treatment wait times more than two months were higher and closer to the front lines.

And that just kind of makes sense. A little bit more what the global cancer community can help for Ukraine. So we would really encourage help with capacity building, educational materials and courses.

Please provide observerships for Ukrainian physicians and research opportunities. Training residents would be important. And if you can participate in teleconsultations for Ukrainian physicians, that would be great as well.

And I would like to say thank you to a large number of stakeholders in Ukraine with whom we work very, very closely. And also people in Boston who have been very generous in providing their expertise to train Ukrainian medical professionals. And I am open to take any questions.