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.