Some information about the country (2001):

Total population - about 48 000 000
Density of population - 84,3 persons/sq.km
Gender composition:
Male - 46 %
Female - 54 %
Life expectancy (years)
Male - 61,1
Female - 72,2
Urban population - 68 %
Rural population - 32%

Introduction

Health of women is a key indicator of population dynamics in the country as it affects the health of future generations. Breast cancer (BC) is one of the mostly widespread malignant-tumour diseases among women in the developed countries. In Ukraine BC results into nearly 30% of tumour-related diseases and 16-18% mortality rate, therefore BC detection is believed to be a priority. As BC incidence tends to grow in the majority of the developed countries, the disease turns from a purely medical problem into a social one.

Epidemiology of BC

In Ukraine BC is rated the highest among malignant tumour-related diseases. According to the statistical data of National Cancer Register 2001:

In Ukraine in 2000 year fall ill with BC 15 227 women. The incidence rates increased more than twice (2,27) within the last 10 years. Ukraine is among leaders in Europe in total number of BC incidence. The incidence rate increased in Ukraine from 22.6 women per 100000 population in 1986 to 53,9 in 1999.

Noteworthy, BC density begins to grow among women 50-54 and is the highest among women 60-64. More than 50% of BC increase are predetermined by the growing disease risk connected with external reasons. Forecast of the Ukrainian society development reveals future pollution of the environment with cancerous chemicals in the wake of chemicalization of industry and agriculture, automobiles increase, nuclear power stations network development, aftermath of Chernobyl nuclear power station catastrophe. Besides change of lifestyle, which enlarges risk factors (increase of smokers among women and teenagers, alcohol abuse, toxicomania, change of reproductive behaviour, change of regime and quality of nutrition etc.) turned out to be of great significance.

Within the last 10 years the highest BC incidence rates were registered in Southern and eastern regions of Ukraine where cancer-related metallurgy and coal mining have always been a priority. In Ukraine the highest rates are fixed in Odessa region, Kharkiv, Dnepropetrovsk region and Kiev City.

The data makes it possible to forecast BC incidence growth up to 58+1,5 in 2002.

Every woman who falls ill with cancer dies at least 17-18 years earlier. 50% of them are women in the best employable age. BC mortality rate increased by 35% from 1986 to 1996. Mortality rate for Ukraine in 1999 was 26,7 per 100000 population One of the most objective indicators is the rate of deaths within one year of diagnosis. This indicator in Ukraine is one of the highest in Europe. In 1999 15 % of women with diagnosed BC have died within one year.

The analysis of BC incidence revealed that the rate of the advance cancer is very high √ 38%. It multiplies the treatment expenses (5-10 increase in comparison with the cases of early detection) and drastically decreases the number of survivors.

BC screening

Oncological assistance provided for the Ukrainian citizens is rooted in the health care system and oncological hospitals network established in the former Soviet Union. BC diagnosis and treatment are performed in Ukraine at the specialised hospitals (oncolological dispancers) located in the regional centres only. Basically, patients are recommended to get a consultation at the specialised hospital (dispancer) after polyclinic doctors, ob/gyn at women consultation centres and at regional polyclinics detect the breast abnormality. BC Screening. Major screening methods are:

• Mammography. The research conducted in 1997 revealed that 95% mammography machines in Ukraine are home-made ⌠Electronica■ machines, 68% of them were manufactured in 1988 and earlier, thus outdated, 31% of mammography machines are unusable. Screening mammography is extremely limited in Ukraine. Mostly it is diagnosis mammography. Radiologists Association of Ukraine headed by Prof. Yakov Babiy, promotes screening programs in Ukraine. Their strategy on mammography screening implementation, which covers the key tasks indicated above, is based on official statistics and mammography database. During last few years for separate medical institutions mammography machines were acquired that has a little bit improved a situation with diagnostic mammography.

• Clinical breast exam (CBE). CBE is a major screening method in Ukraine. It is performed by medical personnel: midwives at peripheral health posts, district doctors at polyclinics, ob/gyn at women consultation centres, surgeons and surgeons-oncologists. In line with the statistics BC detection via CBE in different regions of Ukraine varies from 18% to 40,9%. Some years ago, when annual examination at polyclinics was obligatory for all employees, CBE along with X-ray and cytological cervix examination was a component of overall screening. In line with the Ukase of the Ministry of Health Care of Ukraine every woman, if she addressed a medical institution, had to be screened (BC and cytology) annually. Factually, doctors and midwives provide clinical BC exam not for every woman. It is believed that only 50% of women have CBE. Survey conducted among medical personnel proved that mostly they would like to improve CBE skills.

• Breast self-exam (BSE). BSE remains a vital problem in Ukraine. In some regions at the expense of local and municipal authority posters and booklets on BSE were printed. Some local TV companies produced clips on BSE but the quality and the amount of the materials leave to be desired. TV clips were demonstrated once, not regularly. According to some survey data not more than 3% of women perform regular BSE. Last years due to work of NGOs the information on BSE became more accessible. Since October 2001 company ⌠AVON■ begun BC early detection information and education campaign. Together with NGO ⌠Women Health & Family Planning■ were prepared and distributed more than 300 thousand booklets on BSE.

BC diagnosis

Ukrainian Health Care System makes it possible to perform skilful and rapid overall examination of women with detected malignant tumours. The diagnosis includes CBE by the oncologist and mammography, ultrasound, biopsy to follow. According to the statistical data 70% BC are detected in the oncological dispancers, 30% in the Republican Institute of Oncology, regional hospitals and other medical institutions. High quality diagnosis mammography, as has been stressed above, cannot be performed throughout Ukraine due to the fact that mammography machines are often of low quality or unavailable (for instance, in the Crimea). In the Crimea there is only one mammography machine, in Sevastopol. Breast ultrasound is widely used in Ukraine due to its availability. The majority of medical institutions located at regional centres are equipped with up-dated ultrasound machines (Toshiba, Aloka, Philips, Siemens etc.). Breast ultrasound very often poses an alternative to mammography. All types of biopsy (fine-needle aspiration (FNA), core needle biopsy and surgical (excision biopsy) are used in Ukraine by surgeon-oncologists. Unfortunately core needle biopsy is often unreliable (up to 30% are non-informative), therefor surgeon-oncologists more often use surgical (excision) biopsy. Modern ultrasound control biopsy is seldom used in Ukraine. Ukraine experiences a lack of specialists familiar with the method. Morphological research results are believed to be major confirmation of the BC diagnosis. Pathology-anatomy laboratories are poorly equipped, their personnel number is extremely limited. In Ukraine there are no doctors-pathologists that deal with BC only. Traditionally these doctors carry out all possible research and their workload is extremely high. There is hardly a laboratory, which carries out lab tests of tumour hormonal receptors what complicates further treatment (for instance usage of antiestrogens medication Tamoxifen). Tests to forecast the disease dynamics (HER-2/neu and p53) are not practised widely in Ukraine.

BC treatment

The majority of patients receive complex treatment: surgery, radiation, chemotherapy and hormonal therapy. The treatment is exercises mainly in the oncological dispancers . Analysis of the Cancer Register proves that in 2000 specialised treatment was provided for 77,0% of patients with primarily diagnosed BC.

Surgery: Radical mastectomy (removal of the breast and regional lymphatic nodes) outweighs other surgical approaches. The reason lies in the later stages detection. Many surgeons in Ukraine are familiar with conservative surgery but it is often hardly realisable.

Radiation: Radiation in Ukraine is performed mainly with Cobalt 60 machines (Agat machines manufactured in Estonia). Modern equipment (linear accelerators) is inaccessible. Dosing level is calculated by the doctor-radiologists on the basis of atlases published in the former Soviet Union. The data is not computerised.

Chemotherapy is widely used in Ukraine. The research is scarce whether different combinations of agents were used but the combinations CMF, CAF, AC, CMFP remain the traditional ones. Free chemotherapy agents are not always accessible to patients at the hospitals. They can be obtained at specialised drug stores but the price is usually very high. It is stumbling block for chemotherapy. Besides patients are afraid of complications and side effects of chemotherapy. Because of possible vomiting, hair loss, mouth ulcers, leykopenia patients refuse to take chemotherapy. Modern agents which reduce the side effects are very expensive and patients can hardly afford them.

Hormonal systemic therapy is an effective method of BC treatment. Due to lack of hormonal receptor status Tamoxifen prescription is often ungrounded. Treatment safety is worth mentioning.

Due to economic crisis in Ukraine patients have to buy required agents and other medication for surgery and other treatment. Many families cannot afford it. Many hospitals do not provide nutrition. As patients stay at a hospital a month or longer psychological support becomes important. Generally, surgeons-oncologists and other specialists do not pay any attention to the issue due to high workload., but more often because they neglect the problem. Patients often communicate with other patients or obtain the information from medical sisters.

In Ukraine there are no centres where medical personnel can be trained to provide psychological support. It considerably complicates the rehabilitation process for patients. Information on post-treatment period patients receives from the oncologist. The consultation is verbal and very often does not meet the expectations of the patients and their families. In 1999 the NGO ⌠Women Health & Family Planning■ obtained a grant from International Renaissance Foundation and realised a project ⌠Support and development of psycho-social support to women ill with BC■. For the first time in Ukraine a service of psychosocial assistance to BC patients was organized on the basis Kiev City Oncology Centre. The experience in this field was widely highlighted in mass media and implemented in some oncological hospitals of Ukraine.

State programs, monitoring and medical recommendations

In 1990s the Ministry of Health Care of Ukraine issued a number of orders and recommendations related to oncological service network in Ukraine. Duties and responsibilities of every structural unit were clearly defined. Some orders dealt with high-risk oncological diseases groups as Health Care system remained a state property in Ukraine, its structure has not changed, thus orders and recommendations remain valid. But there is another problem - financial support of the oncological service. Financing has been drastically reduced. Medical institutions are financed from the local budget. It considerably reduced diagnosis and treatment at the oncological dispancers and other structural units entailed many other problems. Now in the process of establishment is National program " Oncology 2002 - 2006 ". The program reflects questions of prevention, early diagnostics, treatment and other. The financial decision of this program is assigned to local budgets that considerably complicates its performance. And nevertheless it is considered by doctors and organizers of Health Care system as the document on the quality standards. One of the most important structural units, which shape state policy within oncological service, is the system of database creation.

In Ukraine there is a single, unified system of oncological documentation, accumulation and processing of statistical data. Every regional oncological dispancer has a centre of medical statistics. Specialists from the centre send their data to the National Cancer-Register. National Cancer-Register is a structural unit within Ukrainian Research Institute of Oncology and Radiology of the Ministry of Health Care of Ukraine. Overall oncological statistics is accumulated and published as a book annually. It covers incidence rates, mortality rate, treatment of oncological patients, including breast cancer patients. Specialists who work for Cancer Register train personnel for regional oncological dispancers. Cancer Register of Ukraine fruitfully cooperates with the International Agency for Research of Cancer (IARC) and Danish Cancer Society.

Periodically, doctors take upgrading courses at the Ukrainian Medical Academy of Postgraduation Education and Oncological Departments within State Medical Institutes. The number of specialized medical periodicals published earlier in abundance is crucially limited nowadays. Periodicals from the USA, Germany and Great Britain are very expensive; thus individual prescription is out of question in Ukraine. Even the Republican Medical Scientific Library cannot afford these editions. Access to participation in international training programmes and scientific conferences are very low. The main reason is lack of financial support. Particularly this problem is actual for the regions of Ukraine. INTERNET access is limited in Ukraine for many medical specialists.

Patients understanding and public awareness

From Soviet period the attitude to oncological diseases was expressed mostly by silence. The majority of the population did not receive any information on prevention and opportunities of early detection of malignant tumours. The problem of oncological diseases was considered exclusively from the medical point of view. Participation of mass media and social movements was extremely limited. Stereotypically, the word "cancer" is often associated with another word - "death" So Ukrainian doctors prefer not to speak frankly about the diagnosis. Official position on the issue was as follows: the patient should be informed about the diagnosis, the word "cancer" is not to be mentioned as it may inflict a psychological trauma. The majority of women were passive while undertake treatment, they were afraid to communicate actively with doctors and medical sisters. Communication with patients in focus groups makes it possible to affirm that many of them would like to have a chance to discuss openly and frankly the disease (mainly with the relations and medical personnel). Their key questions are. Is it necessary to operate on the breast? What are the stages of the disease and how the treatment changes? How many years do I have to live? Due to work of the international organizations and Ukrainian on an extent of 4-5 years the situation gradually began to change from the best side.

Activity of public and international organisations

Since 1996 in Ukraine some International Projects were carried out in the field of struggle against BC. The biggest of them were American International Health Alliance (AIHA) Project ⌠Early detection of Breast Cancer■, USAID/PATH Project ⌠Aid to Ukraine on Breast Cancer in 1997-2000■. A number of the Ukrainian public organizations successfully work in the field of struggle against BC.

 

During last 5 years NGO ⌠Women Health & Family Planning■ actively works in Ukraine. A number of projects were successfully executed due to, which service of psychological and social support of patients with BC was created. NGO also actively works in the area of BC advocacy and informational and educational programs for women. Since 1997 NGO ⌠Women Health & Family Planning■ is the member of the European Breast Cancer Coalition "Europe Donna" and Dr. Galina Maistruk is the Europe Donna National representative in Ukraine.

During last 2 years in some regions of Ukraine (Kharkov, Chernigov, Zhitomir, Nikolaev, Lvov) were created public organisations (NGOs) uniting BC survivors.

Report was created: by Dr. Galina Maistruk,

Dr. Vladimir Bannikov