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Pre-war state of cancer care in Ukraine Cancer is the second leading cause of death in Ukraine, with up to 1.3 million patients and over 150 000 new cases diagnosed in 2022. 1 Under Ukraine’s National Strategy on Non-Communicable Diseases (NCD), most cancer diagnosis and treatment were provided free of charge through universal healthcare (UHC) packages of medical guarantees (PMGs) at 24 regional cancer centres and other certified facilities.2–6 Despite UHC, patients continued to report high out-of-pocket payments, both formal and informal, and lack of trust in doctors and the healthcare system, which both undermined timely access to care.7Modern diagnostic methods, including immunohistochemistry, genetic testing and next-generation sequencing, were available; however, more advanced diagnostics usually required out-of-pocket payment. Cancer drugs from the WHO’s Essential Medicines List were available, while immunotherapy and most targeted agents (eg, cyclin-dependent kinase (CDK) 4/6 inhibitors for breast cancer) were generally self-funded unless obtained through clinical trials.8 Before the war, multicentre trials were active at many regional centres, with hundreds of patients enrolled at some sites at any given time.9The government sought to align guaranteed free care with economic capacity, which expanded user charges. In the absence of official copayments, providers often billed for supplementary services, including diagnostics. Out-of-pocket spending was further driven by high costs of novel drugs outside UHC coverage and by patients seeking private care due to distrust of public-sector quality, particularly in diagnostic pathology. Occasional stock-outs of cancer drugs and surgical instruments also forced patients to pay out of pocket. Some faced delays in imaging, diagnosis or radiotherapy (RT) unless they could pay to expedite care. Nonetheless, overall access to comprehensive cancer care before the war was considered fairly good.Care disruption and patient displacement The full-scale Russian invasion profoundly reshaped cancer care in Ukraine, with outcomes determined largely by geography and security. In areas of active hostilities, hospitals and health services had to prioritise trauma and emergency care over NCD, including cancer. At the beginning of the war, many hospitals were damaged, destroyed or repurposed for trauma care, particularly in the east and south, causing major shortages of cancer drugs, surgical supplies and personnel, particularly in nursing and radiation oncology. 10 In occupied territories, oncology infrastructure was largely destroyed or inaccessible, leading to near-total suspension of specialised treatment (table 1). Occupying forces often used medical facilities for military purposes, further restricting access to routine healthcare, including cancer care.11 Limited, unverified reports described continued cancer treatment in occupied regions, but data on its type or quality were lacking.12 Early assessments emphasised creating resilient oncology hubs and integrating digital medical records to maintain care coordination amid large-scale internal and external migration.Table 1Overview of cancer care indicators in Ukraine before and after the 2022 full-scale invasionIndicatorPreinvasion(before February 2022)Post invasion(2022–2025)InterpretationCancer incidence2019: 138 509 new cases2020: 113 368 new cases2021: 120 055 new cases232022: 105 151 new cases2023: 122 842 new cases92Similar incidence was expected, though many diagnoses were delayed or disrupted and thus less reliably reported.Diagnostic and registration processes were disrupted, leading to likely under-reporting. Decreased incidence mainly reflects late or missed detection and internal/external migration.Cancer mortality2019: 61 289 deaths2020: 55 941 deaths2021: 53 009 deaths232022: 42 660 deaths2023: 44 542 deaths23Apparent decline likely due to incomplete registration, delayed diagnosis and population displacement rather than true mortality reduction.Infrastructure damageCancer centres operating at full capacity. Clinical trial infrastructure intact. RT centres mostly fully functioning.2022: 746 medical facilities damaged and 123 destroyed.93The number of facilities providing chemotherapy fell from 123 in 2021 to 98 in 2022, stabilising at 96 in 2024. 2021–2024: surgical facilities decreased from 427 to 398, while RT centres increased from 33 to 34.29In total, 10 oncology centres have been affected by occupation since 2014, with three additional centres lost since 2022 (figure 1).Oncology hospitals in temporarily occupied areas faced major difficulties, including outdated equipment, restricted international collaboration, workforce shortages and patient discrimination. Facilities in eastern and southern regions experienced substantial patient outflow, while centres in northern, central and western Ukraine absorbed increased patient volumes and now operate at or near full capacity.Patient displacementRelatively stable patient population, most receiving care within their home regions.2025: approximately 3.7 million people are internally displaced, and 6.9 million were refugees abroad.94Host countries’ capacities vary—some are overwhelmed, while others are able to accommodate patients.The war placed significant strain on both Ukrainian and neighbouring health systems. Cancer incidence appeared lower due to delayed detection and migration, with patient redistribution from the East and South toward northern, central and western regions. International partnerships have facilitated patient evacuation, supported systemic therapy continuity and maintained access to treatment.70Treatment delaysUkraine’s UHC generally covered diagnostics, treatment and follow-up. Although waiting times and out-of-pocket costs for advanced diagnostics persisted, the system functioned effectively.Based on an inperson survey of patients receiving care at four regional cancer centres in 2023, most did not report experiencing treatment interruption >1 month as a result of the war. However, those receiving care at the cancer centre closer to the frontline reported greater waiting times for treatment, including chemotherapy and more frequent out-of-pocket payments.79While the number of patients receiving chemotherapy and RT decreased, the number undergoing surgery increased.23Delays occurred primarily near active conflict zones. Some patients sought cancer treatment abroad, particularly for access to novel drugs unavailable in Ukraine but accessible under the EU’s temporary protection framework.21Clinical trials2021: 41 oncology trials were registered in Ukraine, including multiple RCTs.932022: only three new oncological trials registered by May 2022. Most ongoing studies were suspended, with high participant attrition due to displacement.93The invasion caused a sharp decline in research activity, halting trial enrolment and continuity. Consequently, patient access to innovative therapies was significantly reduced.RT service capacityIn Ukrainian government-controlled territories, approximately 44 LINACs (43%) were available for EBRT.692022: RT centres experienced declines in patient throughput:EBRT volume decreased by ~11%.Brachytherapy by ~21%; LDR brachytherapy dropped by ~47%, while HDR declined by ~18%.Staff remained relatively stable, with radiation oncologists decreasing by ~2.9%, medical physicists by ~6.7% and radiation therapists by ~6.5%.69Since the invasion, 21 new LINACs were procured by the MOH and five additional ones procured by regional oncology centres.12Significant reductions in RT activity occurred, particularly for brachytherapy and Cobalt 60 machines capacity, reflecting both infrastructure challenges and patient displacement. Continued modernisation efforts are gradually improving capacity.Financial toxicityMost cancer care costs were covered under UHC, though diagnostics and advanced imaging often required partial or full payment. Some financial burden persisted, but the system remained generally stable.2023: In a survey of patients who received care at four regional cancer centres, many patients reported financial hardship:28–59% received all treatment free of charge.6–27% paid entirely out of pocket.34–66% received partial reimbursement but had to cover diagnostic tests or specific treatments.79Out-of-pocket expenses were more common and higher in facilities near the front line, such as in Kharkiv.79Financial strain has intensified during the war, particularly among displaced and low-income patients. While no major correlation between financial status and waiting times was observed, regional disparities remain substantial.79EBRT, external beam radiation therapy; EU, European Union; HDR, high-dose rate; HDR, high-dose rate; LDR, low-dose rate; LINAC, linear accelerator; MOH, Ministry of Health of Ukraine; RCT, randomised controlled trial; RT, radiation therapy; UHC, universal health coverage.The war displaced about 3.7 million Ukrainians internally and forced 6.5 million abroad, with 4.5 million later returning.13 Neighbouring countries—especially Poland, Romania and Moldova—played key roles in supporting refugees. Poland granted nearly 1 million Ukrainians healthcare access equal to its citizens.14–16 Romania extended public health insurance to refugees, and Moldova helped coordinate paediatric cancer care abroad.17 International support proved critical, though gaps in diagnosis and care continuity persisted.18 Expanding services for women and children remains urgent.19 Organisations like Central European Cooperative Oncology Group have monitored needs and advocated for patients and providers.20 Lviv Oblast absorbed nearly half of Ukraine’s internally displaced population (IDP), straining its health system. Hospitals had to prioritise urgent oncology and postpone elective surgeries, while advanced techniques such as laparoscopy were limited by supply shortages.17Despite numerous challenges, after stabilisation of the front line and redistribution of patients, Ministry of Health (MOH) officials, oncology specialists and patient-advocacy groups agreed that core cancer care modalities in government-controlled regions distant from active combat had largely returned to near pre-war levels by late summer 2022. Importantly, this recovery is unfolding within a fragile and highly variable context: continuity of oncologic care still depends heavily on the resilience of clinicians, the ability of officials to maintain vulnerable supply chains and the capacity of patients to navigate persistent disruptions. Some Ukrainian patients might not fully experience the benefits of this recovery at the point of care, as displacement, insecurity, travel barriers and broader war-related pressures continue to shape and limit access to diagnostics, systemic therapy and follow-up. The restoration also occurred unevenly, with fewer functioning facilities in the South and East and growing patient loads in the North and Centre. In Western Ukraine, patient numbers initially rose due to internal migration and later stabilised as services resumed in home regions and travel abroad for treatment became easier. Today, most patients receive care at regional centres nearest to home, while those requiring novel drugs or unavailable therapies continue to travel abroad under European Commission temporary protection, which grants Ukrainians healthcare access equal to European Union (EU) citizens.21 22Cancer incidence and diagnostic services In 2020, cancer incidence in Ukraine dropped by 18.2%, mainly due to reduced oncology visits during the COVID-19 pandemic ( table 1). That year, 27 100 fewer cancer cases were diagnosed compared with the 2015–2019 average. Although incidence rose by 6.0% in 2021, it remained 13.3% below prepandemic 2019 levels. In 2022, diagnoses fell by another 26 800 (22.3%) compared with 2021, while incidence increased to 122 842 in 2023, the latest data available from the National Cancer Registry.23The war affected early detection and diagnostic capacity, causing major disruptions in laboratory services essential for timely cancer diagnosis. Histopathology and cytology services were severely impacted during the early months of the invasion, with a sharp drop in specimen volume. Nevertheless, some laboratories adapted quickly to wartime conditions by reorganising their cytology operations, relocating facilities when necessary and securing safe housing for staff, which enabled them to restore near pre-war performance within several weeks.24 Initially, cytology processing times increased from 2 days to 3 days to about 5 days but normalised as operations stabilised.Despite wartime challenges, expanding access to cancer screening and diagnostics remains an MOH priority, aligned with efforts to bring national cancer care in line with EU standards. To that end, the Ukrainian Parliament passed two laws supporting and expanding screening for breast, cervical and colorectal cancers.25 26Management capacity Ukraine’s cancer care has shown remarkable resilience amid the devastation of war and limited resources, largely through cooperation between local stakeholders and international partners. 27 Yet some major challenges persist, including early diagnosis, follow-up care and equitable access. A 2022 online survey found that 20.5% of cancer patients faced treatment delays due to the war, high costs, drug shortages, strained doctor-patient relationships, long waits, corruption and limited understanding of treatment plans.28The National Health Service of Ukraine29 collects data through PMGs reimbursed under UHC using the electronic billing service eHealth.30 Between 2021 and 2024, patients receiving chemotherapy for solid cancers under PMGs fell from 102 557 to 71 881, while reimbursed chemotherapy episodes increased from 267 481 to 2 99 821.12 This pattern—fewer patients but more treatment episodes—was consistent nationwide except in the East, where treatment activity dropped sharply and has only partially recovered.31The manifesto on cancer care in conflict-affected populations called for the protection of healthcare under the Geneva Conventions, integration of cancer care into the United Nations (UN) agendas, WHO-led coordination, inclusive care, attention to diverse patient needs and establishment of digital platforms and emergency funding.32 During the war, oncology services prioritised patient and staff safety, adapted treatment protocols, minimised reliance on high-tech equipment and expanded telemedicine use.31Early drug shortages prompted the European Cancer Organisation and the American Society of Clinical Oncology to form a global network of 300+partners supporting data collection and WHO/EU-led relief efforts.17 WHO deployed emergency medical teams, while the EU provided critical aid and included Ukrainian cancer centres into the INTERACT-EUROPE programme to enhance multidisciplinary oncology care.33 Ukraine’s digital platforms Diia and eHealth have been instrumental, giving citizens access to over 30 services from medical support to document filing and financial transactions.34 Since standardised, guideline-driven care is vital for strengthening oncology services both during and after armed conflicts, the National Comprehensive Cancer Network guidelines were translated into Ukrainian, and clinicians received free access to UpToDate, one of the largest evidence-based medical resources.35 Sustainable progress will depend on long-term investment in cancer education, prevention and early detection, supported by continued national and international collaboration.In line with these efforts, a working group, alongside WHO experts in Ukraine, recently reviewed the draft National Cancer Control Strategy through 2030 and its 2023–2025 implementation plan (table 2). The First Deputy Minister of Health stressed alignment with EU standards and requested WHO consultation to support policy development.36 The draft strategy aims to reduce cancer morbidity and mortality, improve quality of life and ensure access to affordable, high-quality care. The implementation plan starting in 2026 is being finalised with consideration for martial law constraints. In a 2023 online survey among Ukrainian oncology specialists, medical oncologists prioritised better access to targeted therapies and immunotherapy, addressing staff shortages and improving chemotherapy and inpatient infrastructure.37 38 Surgical oncologists emphasised disposable supply availability, more operating rooms and personnel, reliable equipment delivery, enhanced training, increased funding and reduced administrative burdens.Table 2Current accomplishments and next steps in strengthening Ukrainian cancer careCategoryAchievements to date (since 2022)Next stepsService continuityCancer care services restored to near pre-war levels by late summer 2022.Oncology centres continued operating under wartime conditions.Maintain uninterrupted cancer services nationwide.Further strengthen emergency preparedness, logistics and interregional coordination.Health system planningAdoption of the National Cancer Control Strategy (2023–2030).Development of a National Implementation Plan (2023–2025).Ensure nationwide rollout of the strategy and implementation plan.Align reforms with EU and WHO standards for integrated cancer control.Screening and early detectionEnactment of national cancer screening legislation (August 2024).Launch pilot nationwide screening programmes for breast, cervical and colorectal cancers.Access to care for displaced patientsEstablishment of the cross-border medical evacuation mechanism.Nationwide access to oncology centres regardless of place of residence.Expansion of internal referral pathways to support treatment continuity.Sustain and scale cross-regional referral networks.Strengthen coordination for displaced populations and integration of electronic medical records.International and cross-border collaborationUkrainian patients received oncology care in EU countries under temporary protection.Sustained collaboration with international donors, NGOs and cancer networks.Strengthen long-term partnerships for workforce training, telemedicine and infrastructure investment.Frontline and high-risk areasContinued encouragement and logistical support for relocation to safer oncology centres.Provision of limited transport assistance for patients.Promote safe referral pathways for oncology care.Expand transport assistance and patient navigation services for residents near active conflict zones.EU, European Union; NGO, non-governmental organisation.Several long-term challenges have the potential to threaten cancer care postwar recovery. Ukraine’s health system is currently completely dependent on international grants and loans to sustain essential services, including cancer care, as domestic revenues are largely allocated to defence. In 2023, the EU provided €18 billion assistance, covering almost half of Ukraine’s budget needs.39 While vital, such dependence raises sustainability concerns should donor support decline. Uncertain long-term funding jeopardises cancer prevention, diagnostics and treatment programmes—many based on short-term or project-specific aid. Meanwhile, the ongoing ‘brain drain’ of oncology specialists due to displacement, emigration and burnout further weakens workforce capacity, risks widening regional disparities and may hinder system reconstruction.40Breakdown in cancer drug supply chains Before the war, Ukraine’s state-funded chemotherapy programmes faced limited funding, recurrent stockouts, outdated infrastructure and insufficiently trained personnel—issues that the war has intensified. Access to targeted and immune therapies declined dramatically. 41 Thousands of cancer patients struggled to continue long-term therapies due to damaged transport routes, blocked warehouses and destroyed pharmacies, particularly in eastern Ukraine. Humanitarian aid to occupied areas was also severely obstructed.42 In government-controlled regions, however, early acute shortages have largely eased.43 In a 2023 survey of 53 oncologists, limited availability (‘available half of the time,’ ‘rarely’ or ‘unavailable’) was reported for 30.1% of 38 UHC-covered cancer drugs for solid tumours.44To mitigate these challenges, Ukraine rapidly revised healthcare regulations. Within the first month of invasion, 29 emergency orders addressed medical and pharmaceutical services, including maintaining proper stocks of drugs for long-term cancer therapies.45 Measures also involved emergency drug registration, relaxed labelling and expiration rules and simplified import procedures.46 Registered drugs can now be imported without Ukrainian-language labelling, and unregistered drugs may be supplied to the military or healthcare institutions, though not for retail distribution. Other steps included expanding ePrescription access, allowing primary care doctors to prescribe for IDP and increasing reimbursement for chronic treatments. Still, these measures cannot fully offset wartime disruptions, underscoring the need for ongoing international support.47Many of these mechanisms build on pre-war procurement reforms. In 2015, MOH partnered with the UN Development Programme (UNDP), United Nations Children’s Fund and Crown Agents to manage medicine procurement—initially a temporary measure through 2020, later extended to 2022. During this period, the state enterprise Medical Procurement of Ukraine was created to assume these functions while adopting UNDP’s quality and transparency standards. Since 2017, UNDP has also funded patient organisations to monitor drug availability and use, enhancing accountability.48 The MOH and Medical Procurement of Ukraine also launched eStock—a digital platform for managing drug and medical device inventories, improving needs assessment and efficiency.49 In the long term, expanding domestic chemotherapy production, particularly in safer western regions closer to international partners, will be essential to secure supply chains and reduce future risks of disruption.Halting of cancer clinical trials Between 2011 and 2021, Ukraine hosted over 2500 clinical trials, including 507 oncology studies registered on ClinicalTrials.gov—140 active, 296 completed and seven terminated ( table 1).50 51 For many patients, these trials were a lifeline and an opportunity to access novel cancer drugs, otherwise unavailable or unaffordable under UHC. In February 2022, just before the invasion, 584 clinical trials were ongoing, 245 of them cancer-related. The war severely disrupted this vital access to advanced treatments, as sponsors suspended enrolment and halted new trial launches. In response, the MOH State Expert Center, which oversees clinical trials regulation, issued guidelines and held online workshops to support Ukrainian oncology patients and sustain ongoing studies.9Between January and October 2022, the number of operating public and private cancer centres fell by 48%—from 1814 to 940.52 Clinical research suffered from unsafe conditions, staff shortages, power outages and communication breakdowns.53 Air transport suspensions delayed delivery of trial drugs, shifting reliance to road and rail, which complicated storage and timely administration.54 Shelling of oncology facilities in Melitopol’ and Chernihiv caused additional drug losses.55 56 To reduce risk, the State Expert Center advised sponsors to follow withdrawal procedures and, when possible, relocate participants to alternative sites in Ukraine or abroad to preserve continuity of care.57Despite these obstacles, many regions away from combat adapted quickly.58 59 Investigators rerouted supply chains, installed generators and Starlink systems and stabilised trial operations.60 Participation in studies abroad, particularly in Poland, also increased. Among 9 94 767 patients treated in Polish cancer centres in 2022, 8000 were Ukrainian. However, Poland’s system faced language, documentation and legal barriers to informed consent. A study from Gdansk highlighted the unmet needs of Ukrainian participants and the necessity for prompt, mutual enrolment decisions to ensure safety.61Although the war’s impact on clinical trials has been unprecedented, Ukraine is rebuilding its standing as a hub for biotech and pharmaceutical research. Regulators have expedited approvals, while companies such as Immunic and Parexel adapted by securing data in the cloud, providing emergency-response tools and relocating patients and staff.62 These wartime adaptations—decentralised trials, remote monitoring and cross-border collaboration—may reshape global research. Ukraine’s commitment to patient-centred design and resilient infrastructure is helping build a more inclusive and sustainable model for future clinical studies.63Disruption and restoration of RT services Even before the full-scale invasion, Ukraine’s radiation oncology system faced significant challenges, including one of the lowest densities of megavoltage (MV) RT machines in Europe—only 1.7 per million people. 64 The annexation of Crimea and partial occupation of Donbas since 2014 had already eliminated 10 RT centres and 18 external beam RT machines (figure 1).65 66 These issues were compounded by reliance on ageing cobalt (Co)−60 units, most manufactured in Russia, making source replacement impossible under current geopolitical conditions (table 1). Other systemic deficits included 16 high-dose-rate afterloaders over 25 years old and in need of replacement, 13 RT centres without CT scanners and only three positron emission tomography (PET)/CT scanners nationwide. Consequently, only 36% of cancer patients receive RT, compared with the recommended 50% benchmark. The 2022 invasion further strained the system: three additional RT centres were occupied, services were temporarily suspended, source exchanges were disrupted and missile and drone strikes caused power outages that interrupted treatment.67 68 As a result, RT patient volume declined by 5500 cases (an 11% decrease compared with 2021), and 68% of regions reported workforce reallocations exceeding 25%.69Figure 1Distribution of radiotherapy and oncology centres before and after the full-scale invasion. PET, positron emission tomographyDespite these challenges, Ukraine’s radiation oncology community demonstrated extraordinary resilience and returned treatment volumes to pre-war levels by 2023, although this recovery does not imply uniform access across all regions, particularly those closer to active hostilities.69 Simultaneously, the country began a large-scale modernisation of its RT infrastructure. Since the invasion, 24 new linear accelerators have been installed, with additional units, three cyclotrons and 15 PET/CT scanners on order. This expansion highlights the urgent need for workforce development as Ukraine transitions from Co-based therapy to intensity-modulated RT (IMRT).Between 2021 and 2024, the number of medical physicists increased by 15.6%, while radiation oncologists and therapists decreased by 11.4% and 6.9%, respectively.69 Both professions remain critically understaffed relative to international benchmarks. Several initiatives aim to close these gaps and enhance RT quality. Policy reforms have officially recognised ‘radiation oncologist’ as a specialty aligned with international standards, and curriculum updates are underway. Efforts are also advancing to establish medical physics as a distinct discipline.To support professional growth, Ukrainian RT leaders have launched national-language training programmes and peer-education networks, while international partners have expanded access to conferences and workshops. Help Ukraine Group (HUG), in partnership with the Union for International Cancer Control (UICC), American Society for Radiation Oncology, European Society for Radiotherapy and Oncology, American Association of Physicists in Medicine, academic institutions and industry, has been instrumental in mobilising global support.69 Their contributions include immobilisation devices for over 10 RT centres, planning software for 30 institutions, 12 training courses and 50 observerships at leading international centres. HUG plans to expand these efforts with Ukraine’s MOH and the International Atomic Energy Agency to align global aid with national strategies and strengthen RT education, infrastructure and care delivery.Despite major progress, certain risks persist. About 39% of MV machines and 75% of brachytherapy afterloaders still rely on ageing Co-60 sources, many irreplaceable under current sanctions. MOH continues to prioritise modernisation and workforce expansion. Although the number of medical physicists is rising, overall staffing and expertise in IMRT and image-guided brachytherapy remain insufficient. Continued national and international support will be essential to secure the RT future in Ukraine through sustained investment in equipment, training and policy reform.Evacuation abroad for treatment continuity In March 2022, MOH requested evacuation support from the EU Healthcare Division. 70 A coordinated system was established for patient data collection, communication with EU nations via the Emergency Response Coordination Center (ERCC) and secure health records sharing, with additional support from WHO. The evacuation protocol has evolved to accommodate various patient groups, including those with life-threatening conditions or requiring highly specialised care. Evacuations typically start within Ukraine, most often through Lviv, and proceed to neighbouring EU countries, with possible further relocation. MOH maintains contact with host nations, while Ukrainian embassies are notified of patient destinations.Despite its complexity, this system has become essential for maintaining cancer treatment continuity during the conflict. Of 639 applications reviewed in April 2023, 339 cases (53.1%) had sufficient data, and 281 patients (82.9%) were successfully evacuated and treated. Under the EU temporary protection mechanism, evacuees receive free medical care across EU states and other participating countries. Initially, Ukrainian cancer centres selected patients independently, but as the programme expanded, expert panels from the MOH and ERCC introduced eligibility criteria and a structured evacuation process to improve fairness and efficiency.Grassroots and non-profit response Patient advocacy groups also rapidly adapted to fill critical gaps. The Kyiv-based ‘Inspiration Family’ used social media to share care options, coordinate drug donations and build international partnerships. 71 Their volunteer network guided IDP through complex referral and evacuation processes, often when official channels were overwhelmed. The group also amplified Ukrainian patients’ voices abroad, advocating for access to treatment and long-term survivorship support. Within the first 3 months of the war, ‘Inspiration Family’ assisted over 100 patients in receiving treatment abroad, launched a Telegram channel with 4,000+ followers and maintained a Facebook page reaching over 6000 cancer patients and survivors, demonstrating the essential role of grassroots advocacy in wartime care.17‘Athena: Women Against Cancer’ is another Ukrainian non-governmental organisation (NGO) defending cancer patients’ rights and supporting them across the care continuum.72 It operates an educational platform, patient hotline and peer-support Facebook group; promotes access to genetic testing for breast cancer and lung cancer mutation testing and advocates for transparency in care costs. ‘Athena’ regularly surveys patients, produces educational materials for both clinicians and patients and strengthens health literacy and advocacy in Ukraine.‘Tabletochki’, Ukraine’s leading paediatric oncology foundation, provides advocacy and direct support for children with cancer and their families.73 It promotes centres of excellence for paediatric oncology, offers financial and logistical support, facilitates medical evacuations and runs palliative care programmes under the EU Beating Cancer Plan.74 Additionally, ‘Tabletochki’ supports postgraduate education for paediatric oncology professionals through observerships and international training.The Global Medical Knowledge Alliance (GMKA), a US-based and Ukraine-based non-profit, builds oncology capacity in Ukraine through open-access, evidence-based education, mentorship and targeted programmes.75 GMKA co-develops an Oncology Center of Excellence with Ukrainian and international partners to assess treatment gaps, deliver biweekly U-COPE ECHO mentorship sessions and organise observerships and hands-on training.76 It also conducts field assessments and surveys on wartime disruptions in cancer care, using these data to guide training, adapt and disseminate clinical guidelines and advocate for supply chain restoration.28 44 77 78 Through partnerships with global cancer networks (eg, UICC) and academic centres, GMKA delivers practical, evidence-based tools for clinicians working under conflict-related constraints.Difficulties faced by patients during their cancer care journey Stories collected through media and surveys since the start of Russia’s full-scale invasion reveal the lived realities of evacuation, financial hardship, psychological distress and care interruptions.Navigating evacuation, diagnosis and treatment pathways Evacuation has been one of the most immediate challenges for patients in active conflict zones. Many travelled long distances across multiple regions to reach functioning oncology hubs, often facing weeks-long delays due to shelling and disrupted transport. In April 2023, online surveys distributed via cancer-focused social media platforms found that among 307 patients, 21.5% reported diagnostic delays and 20.5% treatment delays. The main causes were physician negligence, test costs and long result turnaround times, while treatment delays were attributed to the war, medication shortages and high out-of-pocket costs. 28 Another survey of 522 patients in October 2023 assessed wait times for surgery, chemotherapy, and RT. Half or more of respondents began treatment within 1 month of diagnosis. Gender, age, treatment location, and financial status had no significant impact on wait times among patients who waited over 2 months for treatment.78Financial toxicity Although oncology care is formally covered by Ukraine’s UHC, the war shifted significant costs onto patients ( table 1). Many IDPs faced new expenses for housing, travel, imaging and supportive medications. For those relocated to western regions or abroad, job loss and income insecurity worsened the financial burden. Inperson surveys from four regional cancer centres in 2023 showed that 46% received diagnostics free of charge at public facilities, 43% paid partially and 11% paid in full. The highest proportion of fully paid diagnostics at public facilities was in Kharkiv (27%), closer to the frontline, compared with 6–11% elsewhere.79Psychological distress and trauma Cancer patients are particularly vulnerable, facing both the existential threat of cancer and the impact of war, which can compound one another. Prolonged treatment delays, family separation and uncertainty about follow-up care have triggered high anxiety and depression. Families of children with cancer described the trauma of evacuating without fathers due to military restrictions, while adults reported survivor’s guilt after being prioritised for evacuation. A Turkish hospital treating Ukrainian children identified four key stressors: fear for relatives’ safety, lack of medical records, financial burden and uncertainty about returning home. 80 A case study of a Ukrainian cancer survivor described how fear for family safety and chronic war trauma eclipsed cancer-related concerns.81 Across the wider population, war exposure has been strongly linked to post-traumatic stress disorder (PTSD) and psychological distress. A study of 1001 Ukrainian civilians found that higher exposure to war and danger correlated with more severe PTSD symptoms.82 Together, these findings highlight how fear, instability and displacement compound the stress of cancer itself.Interruptions in palliative and end-of-life care Before the war, Ukraine had very limited access to opioid analgesics for palliative care—averaging only 120 mg morphine equivalent per patient with serious illness, meeting just 7% of national needs. 83 The war disrupted cancer treatment continuity, causing some curable cases to progress to stages requiring palliative care.27 Secondary and community palliative services have been severely affected by infrastructure damage, staff evacuation and mass displacement, further straining the system.83 84 One systematic‐style review of literature (in Ukrainian) found ‘insufficient pain relief for palliative care patients in Ukraine’, with war conditions worsening the situation.85HelpAge International reported that older people with serious illnesses face severe pain, anxiety and trauma exacerbated by conflict.86 Home and community-based palliative care, preferred by many individuals, is often unavailable. Caregivers, mainly family members, face similar emotional strain. Despite this, older adults and caregivers demonstrate resilience through acceptance, spirituality and self-reliance. These experiences underscore the urgent need to strengthen Ukraine’s palliative and long-term care systems by expanding home and community-based services, integrating multidisciplinary teams and improving training and support for health and social care providers.87Broader lessons for cancer care in conflict settings The war in Ukraine demonstrates how oncology services can adapt rapidly during a full-scale invasion in which much of the country remains under government control, unlike the prolonged, fragmented conflicts seen in parts of the Middle East. Swift action by Ukrainian authorities and international partners enabled the relocation of patients and healthcare personnel from high-risk to safer regions in the North, Centre and West. Cancer drugs were redistributed based on patient volumes, and medical evacuations were coordinated through the MOH with EU and global partners. 70 Despite damage, staff shortages and supply disruptions, access to essential cancer care was largely restored within 6 months. This experience underscores the importance of centralised planning, cross-border cooperation and flexible service delivery in maintaining oncology care during acute crises.In contrast, Gaza illustrates how political fragmentation, mobility restrictions and recurrent conflict undermine cancer treatment. Patients requiring RT or specialised care must obtain Israeli-issued permits to access hospitals in East Jerusalem or the West Bank—a process often suspended during hostilities. In 2023, over 40% of Gaza cancer patients experienced treatment delays or denials, according to WHO.88 Unlike Ukraine’s relatively centralised and internationally supported response, Gaza’s dependence on ad hoc approvals and restricted movement creates chronic vulnerabilities in care continuity.Similar patterns appear elsewhere. In Iraq, during the Islamic State occupation, cancer services were hampered by poor diagnostics, long waiting times, degraded RT infrastructure and counterfeit drugs.89 In Syria and Sudan, protracted conflicts have collapsed oncology services, reflecting consequences of underinvesting in health-system resilience.90 91Despite differing contexts, several cross-cutting lessons emerge. Ukraine’s rapid recovery highlights the value of structured cross-border mobility, centralised coordination and international collaboration—models that could improve cancer care in Gaza, Syria and Sudan. Formalised evacuation mechanisms and regional referral systems can mitigate access barriers. Similarly, decentralisation and task-shifting, such as training generalists and nurses to provide chemotherapy or palliative care (already used in parts of the Middle East), could be applied in Ukraine and elsewhere to address workforce shortages during emergencies. Across all conflict settings, protecting critical infrastructure such as RT units, maintaining spare parts and power supply, digitising cancer registries and securing drug supply chains remain fundamental for both crisis response and long-term resilience.Sustained international engagement through telemedicine, workforce training and medicine donations has proven essential in both Ukraine and the Middle East. Building flexibility into cancer systems through legislative reforms and emergency protocols allows patients to access care wherever available. Logistics must also evolve: smaller, more frequent drug shipments, mobile clinics and dynamic procurement models can meet shifting needs. Strategic investment in oncology services within safe zones and clearly defined referral pathways ensures continuity of care. Finally, collaboration among hospitals, NGOs and government agencies, whether formal or informal, is critical for sharing resources and expertise to maintain cancer care amid instability.Strategic priorities for Ukrainian cancer care in wartime and beyond Although core cancer care modalities in safer regions of Ukraine had largely returned to pre-war levels by mid-2022, access remains uneven and recovery continued to depend on the stability of infrastructure, workforce and supply chains. To ensure sustainability, reduce reliance on external aid and strengthen long-term resilience, Ukraine must focus on optimising its oncology system ( table 2). These strategic priorities define the next phase of response and recovery, relevant not only for Ukraine but also for other countries affected by war or humanitarian crises.Maintaining a consistent and reliable supply of oncology medications covered through UHC remains paramount. Uninterrupted access to essential and generic drugs must be guaranteed, while improving the availability of targeted therapies—particularly for breast, lung and haematological malignancies—should remain a priority. A stable supply chain will reduce the need for patients to seek treatment abroad and rebuild trust in the national health system. Equally important is securing and retaining a skilled oncology workforce. Expanding the number of trained radiotherapists, radiologists, physicists and technicians, supported by continuous education and maintenance programmes, will help maximise existing investments and expand access to modern care across regions.Strengthening early detection and prevention programmes is another core objective. Scaling up pilot screening initiatives and prevention efforts, in alignment with new national legislation and in collaboration with WHO, UICC and the International Agency for Research on Cancer, will help align Ukraine’s practices with international standards and improve outcomes at the population level. Finally, advancing quality improvement across the cancer care continuum is critical. Developing standardised quality indicators and embedding regular performance measurement and feedback systems in cancer centres will promote evidence-based decision-making, enhance accountability and enable Ukraine to monitor and continuously improve its oncology services.Conclusions This review outlines how Ukraine’s oncology system endured and adapted during the full-scale Russian invasion. It documents major disruptions in diagnostics, treatment and research, alongside the rapid service reorganisation and close coordination between national authorities, clinicians and international partners. Despite infrastructure damage, workforce losses and supply-chain interruptions, core cancer care in government-controlled areas largely recovered to near pre-war functional levels within 6 months, supported by resource redistribution, emergency regulations and digital platforms that ensured continuity. However, this recovery remains uneven and dependent on the resilience of clinicians, the stability of logistics and infrastructure and patients’ ability to navigate ongoing disruptions. Ukraine’s experience shows that maintaining cancer care during armed conflict is possible when supported by centralised coordination, flexible policy and international collaboration. It also demonstrates that short-term emergency measures, when paired with investment in workforce development, quality improvement and data systems, can build the foundation for long-term resilience. The lessons from Ukraine offer a framework for protecting and rebuilding cancer and other NCD services in regions affected by war and humanitarian disaster.