INTRODUCTION
One of the main consequences of armed conflicts on children and their
families is the need, in many cases forced, to leave their country. At
the end of 2022, the United Nations High Commissioner for Refugees
(UNHCR) estimated that the number of people forced to flee their
countries amounted to 108.4 million.1 This number
included refugees, asylum seekers, internally displaced persons and
others who required international protection but were not included in
those protected by UNHCR. Of these, 40% were children.
It was estimated that more than 5.9 million Ukrainian refugees have
found shelter in neighboring countries (as of December 31, 2023), and
that more than 5 million Ukrainians are displaced within their own
country. The majority of refugees were women and children (the latter
represent around 40% of the total quota), given the ban on male
Ukrainian citizens leaving the country.2
Apart from common diseases and prevention activities that could become
impaired during war times, children exposed to wars and fleeing from
them are at greater risk of toxic stress, consisting of the repetition
over time of extreme and persistent adverse events, in the absence of
support and care.3 These events may include the death
of a family member, a life-threatening illness, a natural or man-made
disaster, and terrorist attacks. Children may show a wide range of
stress reactions that include specific anxiety, prolonged crying,
disinterest in the surrounding environment, psychosomatic symptoms and
aggressive behaviors.
The effect of the current conflict on pediatric cancer care in Ukraine
and in countries receiving its refugees depends on many factors. First
of all, the safety of patients and medical staff, the compliance with
the basic requirements of therapeutic protocols, the prevention of human
errors during medical procedures, the regulation of patient flows
according to the intensity of combat, the use of medical or surgical
interventions with minimal and manageable risk of complications.
During the early months of the conflict, a classification of war zones
was proposed to help understand whether these tasks could be
continued4 .
Based on the available information, four zones were established
regarding the feasibility of the oncological treatments: the first zone
was that of active hostilities or humanitarian disaster, where no
oncological treatment was possible and priority was given to the
transfer of patients to facilities located in the fourth zone or in
nearby available countries. In the case of particularly severe condition
patients who required immediate stabilization, transfers were made to
the second area. The second zone was at high risk of bombing or other
humanitarian problems. The third zone, with medium probability of
bombing, was a humanitarian alert zone. Finally, the fourth zone, where
the probability of bombing was low, was defined as one of humanitarian
stability. In the transition from zone 1 to zone 4, treatment gradually
changed from impracticable to somewhat similar to what was offered prior
to the conflict, with a progression of availability that started from
the consultation and through diagnosis and transfer culminated in the
treatment. In the transition between the first and second zones, medical
care was carried out mainly on an outpatient basis. With transition to
other areas it gradually became possible to increase the frequency of
appointments and even create some places for hospital
admission.4
Based on the Ukrainian epidemiological situation immediately preceding
the conflict, it was estimated that, in the first months of the war,
there were approximately 33,000 cancer patients (approximately 1% were
pediatric) within the refugee population, distributed among neighboring
countries in a non-uniform way.5
The devastation of war resulted in a delay in access to prescribed
treatments, both for patients who remained in Ukraine and for those
forced to emigrate and face slowdown in care due to their resettlement
(both bureaucratic and healthcare).6 One of the worst
consequences of these delays may be the increase in cancer mortality,
directly proportional to the extent of the delay and which affected all
types of treatment.7
Soon after the start of the war, in Feb 2022, it rapidly became clear
that we were faced with an enormous humanitarian crisis that also
involved also children and adolescents with cancer obliged to interrupt
their treatment.
The international paediatric oncology community has been trying to find
ways and resources to deal with this emergency, and many paediatric
oncology centres in Europe were asked to receive patients from Ukraine.
On March 7, 2022, the Lombardy Regional Authority granted free care for
pediatric patients with cancer. The evacuation was coordinated by the
establishment of a patient triage hub in Poland to ensure the safe and
rapid transfer of children from Ukraine to appropriate medical
facilities in other countries8.
The aim of this study was to evaluate the effect of the forced
abandonment of their own country on the pediatric oncology population
arriving from Ukraine in the period between May and November 2022,
through questionnaires administered to the patients’ mothers in two
different pediatric-oncology centers in northern Italy, i.e. Istituto
Nazionale dei Tumori, in Milan, and Policlinico San Matteo, in Pavia.