War and the fragility of anticancer drug supply networks in Ukraine — Abstract

Background: Systemic therapy availability in Ukraine is fluid due to the war. This information is key to optimizing cancer care.

Methods: Online surveys assessing cancer treatment capacity were distributed to physicians in Ukraine through cancer-focused social media in April 2023. Results were analyzed with descriptive statistics and Fisher’s exact test.

Results: 15 oncologists from 14 oncology centers and 12 hematologists from 9 hematology centers completed surveys, including 3 (25%) and 4 (27%), respectively, from the more war-affected Northern, Southern, and Eastern Ukraine.

Of the 36 drugs used for solid tumors, limited availability (half of the time, rarely available, or unavailable) was reported for 11 (31%) drugs by 2-4 (14-29%) respondents: cisplatin, cyclophosphamide, doxorubicin, etoposide, fluorouracil, ifosfamide, methotrexate, vincristine, filgrastim, dexamethasone, tamoxifen. 7 (19%) had limited availability per 5-6 (36-42%): capecitabine, irinotecan, mesna, anastrozole, leuprolide, zoledronic acid, erlotinib. 12 (33%) drugs were limited per 7-8 (50-57%): abiraterone, bleomycin, carboplatin, docetaxel, gemcitabine, oxaliplatin, paclitaxel, vinblastine, vinorelbine, folinic acid, bicalutamide, trastuzumab. 7 (19%) were limited per 8-13 (57%-93%): nivolumab, diethylstilbestrol, bevacizumab, palbociclib, trastuzumab emtansine, sorafenib.

Of 31 drugs used for hematologic malignancies, 4 (21%) were limited in availability per 2-4 respondents: vincristine, bortezomib, imatinib, azacitidine. 5 (16%) were limited per 5-6: bendamustine, filgrastim, doxorubicin, lenalidomide, hydroxycarbamide. 10 (32%) were reported to be limited by 7-8: rituximab, thalidomide, vinblastine, chlorambucil, bleomycin, methotrexate, daunorubicin, nilotinib. 10 (32%) were limited per 9-12: ibrutinib, mercaptopurine, eltrombopag, erythropoietin, thrombopoietin, ruxolitinib, venetoclax, brentuximab, gemtuzumab, obinutuzumab.

Drug availability did not differ by country region (p > 0.05).

Conclusion: Shortages of essential anticancer drugs are a continued challenge in Ukraine during the war. Results are limited by small sample size and limited sampling from regions affected by active hostilities.

Of 36 drugs commonly used in Ukraine for treatment of solid tumors and 21 drugs used for treatment of hematologic tumors, 32 (89%) and 14 (45%) were part of the 2021 WHO Essential Medicines list.

90 physicians completed surveys, 15 (17%) medical oncologists, 12 (13%) hematologists, 35 (39%) surgeons, 13 (14%) radiation oncologists, 9 (10%) radiologists), 3 (3%) pathologists, and 2 (2%) palliative care physicians. All regions of Ukraine except for Donetsk and Crimea were represented. 76 (84%) of respondents were from public healthcare centers, including 20 (22%) from Kyiv region, 22 (24%) Central, 23 (26%) Western, and fewer from the war-affected East 9 (10%), North 7 (8%) and South 13 (14%).

Drug availability was reported to be higher by the one private clinic survey participant. Reported wait times for a new chemotherapy start were < 1 week per 9 participants (60%), 1-2 weeks per 3 (22%), 2-3 weeks per 2 (13%). There was only one oncology center where two medical oncologists filled out surveys allowing for comparison of responses; they provided different answers related to personnel and equipment volume, and had different perceptions about drug availability.

For hematologic malignancies, reported wait times to start treatment were also short. There was more concordance in reporting of staffing and treatment availability within hematologic centers (Lviv, Sumy).

Of the 14 drugs on the 2021 WHO EML, 3 (21%) were limited in availability per 2-4 (16-33%) respondents: vincristine, bortezomib, imatinib. 5 (36%) were reported to be limited by 5-6 (41-50%): bendamustine, filgrastim, doxorubicin, lenalidomide, hydroxycarbamide. 8 (57%) were reported to be limited by 7-8 (58-66%): rituximab, thalidomide, vinblastine, chlorambucil, bleomycin, methotrexate, daunorubicin, nilotinib. Two (14%) were limited per 9-12 (75-100%): ibrutinib, mercaptopurine, as were 8 (47%) of the 17 drugs not on the WHO EML: eltrombopag, erythropoietin, thrombopoietin, ruxolitinib, venetoclax, brentuximab, gemtuzumab, obinutuzumab. Of the other drugs not on the EML list, azacitidine availability was reported as limited by 2-4 respondents, and aspraginase and bosutinib by 7-8.

Authors: Olha Kostenchak-Svystak (1), Darya Kizub(2), Vyacheslav Kopetskyi(5), Mila Reutova, Anna Uzlova, Inesa Matiushenko, Ali Dzhemiliev(3,4), Inesa Huivaniuk(5), Mariia Kasianchyk (6) Andriy Beznosenko, Nelya Melnitchouk (3,4).