Introduction
Following the full-scale Russian invasion of Ukraine on the 24th of February 2022, millions of Ukrainians have fled the country. Almost 3.5 million war refugees crossed the Ukrainian-Polish border during the first two months of the war [1]. A large proportion of these refugees subsequently migrated to other countries; however, according to Polish government data, one year after the start of the war, nearly 1 million Ukrainian refugees were registered in Poland with full access to medical care. Of this group, 77% of adult refugees were women [2].
Breast cancer (BC) has the highest incidence among all malignancies in women in Ukraine. The start of the war, followed by mass migration of refugees, coupled with war-related disruptions in the functioning of healthcare services led to a sharp decline in BC incidence in Ukraine in 2022 [3]. On the contrary, the number of Ukrainian oncological patients increased in Polish hospitals. A regional cancer center in Kraków, Poland, noted that Ukrainian citizens had constituted up to 13% of all first-time patients in the third week of the war — predominantly women, among whom the largest proportion had BC [4].
The treatment of Ukrainian refugees with cancer in Poland faces several challenges. These include the language barrier, missing medical records, differences in the diagnostic work-up of oncological patients, and type of treatment offered in the two countries [4, 5].
This study performs an analysis of basic clinical and epidemiological characteristics of Ukrainian patients with BC who had their first-time oncological consultation at the Greater Poland Cancer Centre (GPCC) in Poznan, Poland, in 2022.
The GPCC is a hospital in Western Poland offering comprehensive BC diagnostics and treatment. Multidisciplinary team (MDT) meetings held regularly at the GPCC help establish the clinical staging of BC and plan oncological treatment.
Material and methods
This is a single-center, retrospective, cross-sectional study. All patients with BC [International Statistical Classification of Diseases and Related Health Problems 10th ed (ICD-10) codes C50, D05] and Ukrainian citizenship who had their first-time oncological consultation at the GPCC in 2022 were enrolled in the study. This included patients diagnosed with BC at the GPCC as well as outside our institution.
Data extracted from the hospital information system (Eskulap, Nexus Polska Sp. z o.o.) included the date of the first-time oncological consultation at the GPCC, the year and country of BC diagnosis, age at time of BC diagnosis and at time of first visit to the GPCC, and clinical staging of BC. Clinical stage was determined based on available medical records from both Poland and Ukraine. Medical records of each patient were further evaluated to ascertain if treatment for BC had been conducted at the GPCC (such as surgical management, radiotherapy, brachytherapy, chemotherapy, hormone therapy, physiotherapy). Diagnostic tests (imaging and biopsy) were not considered as treatment.
Additionally, BC MDT data on patient age and clinical stage from 2022 were extracted from the hospital information system to serve as a comparison for the study population.
A total of 106 female patients with Ukrainian citizenship and invasive or in situ BC presented for the first time to the GPCC in 2022. Out of this group, 3 patients had bilateral BC increasing the number of BC cases to 109. Due to missing medical records, some cases were excluded from part of the analyses:
- • in 5 cases out of 109 (5%) information was missing on the date of BC diagnosis;
- • in 5 cases out of 109 (5%) we were unable to establish patient age at BC diagnosis;
- • in 1 case out of 109 (1%) we were unable to establish the country of BC diagnosis;
- • in 3 cases out of 109 (3%) we were unable to establish the country of BC treatment initiation (additionally in 1 case diagnosed in Poland treatment was refused);
- • in 24 cases out of 109 (22%) we were unable to establish BC stage.
This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [7]. Ethical review and approval were waived by the Ethics Committee of the Poznan University of Medical Sciences as our study was not classified as a medical experiment.
Descriptive statistics (median values, percentages) were calculated using Microsoft Excel.
Results
First-time visits for all 109 BC cases enrolled in the study took place after the start of the full-scale war on the 24th of February 2022, with the greatest number of first-time visits in March 2022 (Fig. 1).
Most cases of BC in the study population were diagnosed in 2022 (28 out of 104 — 27%); however, some patients presented to the GPCC several years after the diagnosis — with some patients diagnosed as early as 1993 (Tab. 1). The majority of cases (82 out of 104 — 79%) presented to our institution within five years of BC diagnosis.
|
Year of cancer diagnosis |
Number of cases |
Percentage values |
|
1993–2011 |
6 |
6% |
|
2013–2017 |
16 |
15% |
|
2018 |
13 |
13% |
|
2019 |
11 |
11% |
|
2020 |
12 |
12% |
|
2021 |
18 |
17% |
|
2022 |
28 |
27% |
|
Total: |
104 |
100% |
The GPCC BC multidisciplinary team (MDT) reviewed a total of 1382 cases in 2022, with a median age of 61 at time of MDT evaluation. The median age at diagnosis for the study population was 47, while at first visit to the GPCC, 51 (Tab. 2, Fig. 2).
|
Age groups |
Study population at time of diagnosis |
Study population at first visit to GPCC |
Age at 2022 BC MDT for all GPCC patients |
|||
|
Number of cases |
% |
Number of cases |
% |
Number of cases |
% |
|
|
15–39 |
26 |
25% |
18 |
17% |
80 |
6% |
|
40–49 |
34 |
33% |
35 |
32% |
254 |
18% |
|
50–69 |
38 |
37% |
46 |
42% |
724 |
52% |
|
70+ |
6 |
6% |
10 |
9% |
324 |
23% |
|
Total |
104 |
100% |
109 |
100% |
1382 |
100% |
|
Median age |
47 |
|
51 |
|
61 |
|
Out of 108 cases, only 26 (24%) were diagnosed in Poland and 82 (76%) in Ukraine.
In the group of 82 cases diagnosed in Ukraine, 2 patients were later diagnosed with metastatic disease and 1 with local recurrence in Poland. In the group of 26 cases initially diagnosed with BC in Poland, 18 were diagnosed at the GPCC.
The country of cancer diagnosis correlates well with the country where oncological treatment was initiated – in 80 cases (76%) treatment was started in Ukraine, in 25 cases (24%), in Poland (Tab. 3).
|
|
Country of BC diagnosis |
Country of BC treatment initiation |
||
|
Number of cases |
% |
Number of cases |
% |
|
|
Ukraine |
82 |
76% |
80 |
76% |
|
Poland |
26 |
24% |
25 |
24% |
|
Total |
108 |
100% |
105 |
100% |
The majority of cases (71 out of 109, 65%) were treated for BC at the GPCC. This includes patients who initiated treatment at the GPCC (17 cases) in addition to those who presented to our institution for continued treatment that had already been started elsewhere (in 44 cases in Ukraine, in 8 cases in Poland, unclear location of previous treatment in 2 cases). In 38 cases (35%) no treatment was performed at the GPCC — this group comprised of patients who did not attend further planned appointments or who refused medical care at our institution (Tab. 3). It is also worth noting that out of 80 cases initially treated for BC in Ukraine, the majority (44 cases — 55%) had their treatment continued in our institution. Moreover, cases initially treated in Ukraine, that required continued oncological care, constituted the majority of all cases treated at the GPCC (44 cases out of 71 — 62%).
|
|
BC treatment at the GPCC |
Continued BC treatment at the GPCC for cases already treated in Ukraine |
||
|
Number of cases |
% |
Number of cases |
% |
|
|
Yes |
71 |
65% |
44 |
55% |
|
No |
38 |
35% |
36 |
45% |
|
Total |
109 |
100% |
80 |
100% |
Among the study population cases with stage II BC were most numerous (31 cases, 36%), followed by stage IV BC (22 cases, 26%) and stage III BC (18 cases, 21%). There were only 13 cases of stage I BC (15%) and 1 case of stage 0 (in situ) BC (1%).
Out of the relatively large number of 24 cases excluded due to missing documentation on BC stage, only 2 were treated at the GPCC.
Table 5 and Figure 3 compare BC stage of the study population with MDT data for all BC cases evaluated at the GPCC in 2022 (6 MDT cases out of 1382 were excluded due to missing data). Not all patients from the study population were evaluated by the MDT.
|
Stage |
Study population |
BC MDT data for 2022 |
||
|
Number of cases |
% |
Number of cases |
% |
|
|
0 |
1 |
1% |
105 |
8% |
|
I |
13 |
15% |
475 |
35% |
|
II |
31 |
36% |
562 |
41% |
|
III |
18 |
21% |
155 |
11% |
|
IV |
22 |
26% |
79 |
6% |
|
Total |
85 |
100% |
1376 |
100% |
Discussion
Poland had a large, predominantly male, Ukrainian diaspora before the outbreak of the full-scale war in Ukraine in February 2022. The war has led to a significant change in the demographics of Ukrainians living in Poland, with females now constituting the overwhelming majority of adult refugees [1]. This demographic shift is a likely explanation for no recorded first-time oncological consultations of Ukrainian citizens with BC at the GPCC in January and February 2022, with a peak in first-time appointments in March 2022 (after the Russian invasion). Although in our study we focused solely on data available in the hospital information system, and did not review passport border crossing entries or immigration statuses, the monthly distribution of first-time oncological consultations at our institution strongly suggests that Ukrainian patients with BC who presented to the GPCC for the first time in 2022 were mostly refugees. This claim is also supported by the high proportion of cases diagnosed with BC in Ukraine in the study population (76%).
The majority of Ukrainian patients with BC who presented to the GPCC in 2022, regardless of the country of diagnosis, decided to have their oncological treatment at our institution (65%) — mostly continued oncological care after previous treatment in Ukraine. These findings are comparable with a report from the National Cancer Institute (NIO) in Kraków, Poland, which analyzed a total of 304 cancer cases among Ukrainian refugees, with 68% treated at the NIO [8].
In line with other publications, our study demonstrated that missing medical records are a significant problem in the oncological treatment of Ukrainian patients in Poland. We were unable to establish the clinical stage for 24 out of a total of 109 BC cases enrolled in the study (22%) [4, 5, 8].
The most striking difference between the study population and all BC patients reviewed by the GPCC MDT in 2022 lies in patient age and clinical stage. Ukrainian patients who presented to our institution after the outbreak of the full-scale war were in most cases diagnosed with BC before the age of 50 (60 cases — 58%). In contrast, patients under the age of 50 constituted only 24% of all BC cases evaluated by the MDT in 2022 (334 cases). The majority of cases evaluated by the MDT (724 cases — 52%) were diagnosed in patients aged 50–69, which represented the screening age group at the time (BC screening age group in Poland between 2005–2023). A similar age distribution, with a small (< 25%) proportion of BC cases in patients under the age of 50 was also observed in MDT data from the years 2019–2021 at our institution, which highlights the exceptionally high proportion of young patients in the study population [6]. The likely explanation for the age distribution observed in our study lies in the demographics of refugees. According to a study analyzing applications for the Polish national identification number (PESEL) among Ukrainian refugees, as of May 19, 2022, a total of 797,128 females applied for PESEL. In this group 561,159 (70%) were aged < 40, and 705,779 (89%) were aged < 55 [9].
Stage II BC was most commonly diagnosed both in the study population and among patients reviewed by the GPCC BC MDT in 2022. It is, however, worth underscoring the relatively small percentage of stage II BC cases in the study population (36%), compared with all MDT cases (41%). Moreover, metastatic BC (stage IV) was the second most commonly diagnosed stage among Ukrainians with BC presenting to the GPCC for the first time in 2022 (26%), whereas in MDT data for the years 2019–2022 stage IV BC was consistently the least commonly diagnosed, never exceeding 7% of all cases. Additionally, the percentage of stage 0 and stage I BC cases was unusually low in the study population (1% and 15%, respectively) when compared with MDT data from the same year (8% and 35%, respectively) as well as previous years (2019–2021) [6]. The stage distribution suggests that in the face of the war Ukrainian patients with advanced BC requiring long-term oncological treatment were more likely to seek continued oncological treatment outside their country. This claim is also supported by the large proportion of cases in the study population that were diagnosed at least a year before the start of the war (58 out of 104 cases diagnosed between 1993 and 2020 — 56%). Furthermore, nearly all Ukrainian patients diagnosed with stage IV BC in the study population (21 cases — 95%) continued oncological treatment at the GPCC, while only 71 cases (65% of the total enrolled) sought treatment at our institution.
Our study demonstrated a high proportion of stage III (21%) and stage IV (26%) BC cases among Ukrainian patients who presented to our institution in 2022, requiring ongoing medical care. Other studies from Poland demonstrated a significant influx of Ukrainian patients to Polish hospitals following the start of the war (including patients with malignancies) or estimated a considerable disease burden of Ukrainian refugees [4, 9–11]. At the same time the Polish healthcare system still suffered from increased strain due to COVID-19 related disruptions. According to the OECD data, in the spring of 2022, patients in Poland reported one of the highest percentages of unmet medical care needs in the European Union [12]. The pandemic-related restrictions were in force in Poland until May 2022 [13]. It seems, therefore, that the increased demand on Polish healthcare resulting from mass migration of refugees coincided with the ongoing COVID-19 crisis.
Potential limitations of the study
Our study compares datasets that are not fully compatible. We analyzed all first-time oncological consultations of Ukrainian citizens with BC at the GPCC in 2022, regardless of whether they continued treatment at our institution. This data was then compared with 2022 BC MDT records from our hospital, which do not represent the entire population of patients with BC presenting to the GPCC in that year (as it may not include a proportion of Polish citizens who decided to pursue treatment in other hospitals). Therefore, our study cannot provide a valid estimation of the proportion of Ukrainian patients among all BC patients who presented to the GPCC in 2022.
Another important limitation of our study is that we were unable to establish cancer clinical staging for 22% of the relatively small study population – due to missing medical records.
Suggestions for further research
The majority of Ukrainian patients with BC who presented to the GPCC for the first time in 2022 underwent treatment at our institution, often receiving continued oncological care for advanced BC. Further research is required to analyze the exact type of treatment performed at the GPCC (such as surgery, chemotherapy or radiotherapy) in order to fully assess the medical needs of refugees and establish the additional workload placed upon the hospital.
Considering the high number of patients from Ukraine with missing medical records, a study comparing BC treatment regimens in Poland and Ukraine could facilitate the continued, long term treatment of Ukrainian cancer patients in Polish hospitals.
Our single-center study presents a limited perspective on the oncological treatment of Ukrainian refugees in Poland. Large scale, nationwide research is required to better understand the impact of the war on refugees with cancer as well as to assess the consequences of the sudden mass migration of Ukrainians for the Polish healthcare system.
Conclusions
The population of Ukrainian patients with BC who presented to the GPCC for the first time in 2022 was characterized by relatively young age at diagnosis and more advanced disease when compared with all BC patients reviewed by the MDT at our institution. The biggest influx of Ukrainian patients was observed in March 2022, soon after the outbreak of the full-scale war. Most Ukrainian patients in the study population had already been diagnosed and treated for BC in Ukraine, and the majority of those treated in Ukraine chose to continue their oncological care at the GPCC. Furthermore, cases initially treated in Ukraine, requiring continued oncological care, constituted the majority of all cases treated at the GPCC.
Author contributions
P.R.; M.T. — writing, original draft preparation; M.F.; M.L.; W.K. — review for critical intellectual content.
Conflicts of interest
The authors declare no conflicts of interest.
Funding
None declared.
Ethical permission
Ethical review and approval were waived by the Ethics Committee of the Poznań University of Medical Sciences as our study was not classified as a medical experiment.