Bridging Oceans, Docs Rally to Save a Ukrainian Cancer Patient

Kate Johnson

March 31, 2022

Cancer centers around the world have taken in patients who have been evacuated from war-torn Ukraine, but continuing their care can be fraught with logistical problems, not least of which is language.

In the case of one 2-year-old boy, it took efforts of doctors in different countries with different specialties to make sense of the exact diagnosis and how to proceed with treatment.

He was one of the last cancer patients to be evacuated from Ukraine's biggest children's hospital in Kyiv.

The boy had been left behind after the initial evacuations because he had an extremely rare form of leukemia, and his doctors likely wanted him to complete his first round of chemotherapy in an attempt to arrest the disease.

But as the shelling intensified, the decision was taken to move him, too, even though he was 10 days into the treatment and was very vulnerable, with an immune system that had been virtually wiped out by the chemotherapy.

A hastily written discharge summary was thrust into his parents' hands before they boarded a flight out of the country.

Two days after the boy's evacuation, an oncologist half a world away from the patient was poring over his medical file, trying to translate it into English for his new doctors in London.

"The last line in the discharge summary said, 'rapid evacuation under major disaster circumstances...semicolon….War,' " said Layla Shbat, MD, a Ukrainian-born medical oncology fellow at the McGill University Health Center (MUHC) in Montreal, Canada.

"As I was typing, honestly, my heart just kept on sinking and sinking," she told Medscape Medical News. "He had a horrific form of cancer with involvement in multiple organs, he had horrible infections because his immune system had been completely wiped out by his induction chemo regimen, and on day 10, which is the most dangerous phase, he was put on a plane."

Shbat's expertise was sought by her colleague and Ukrainian-speaking friend, Artem Luhovy, MD, a Montreal family doctor involved with the MUHC Centre for Global Surgery. A team from this center has been collaborating with Ukrainian hospitals since the start of the 2014 Russo-Ukrainian war.

That was how he had met Kristina Dzhuma, MD, now at London's Great Ormond Street Hospital for Children, where the little boy had been admitted.

"Kristina was overwhelmed translating Ukrainian patients' charts," said Luhovy, and he offered to help. He took on medical records to translate, and then turned to Shbat for further assistance.

But the file on the young boy arrived in the middle of her busiest clinic of the week, and Shbat had no chance to look at it until the next day. It was written in Ukrainian, which she doesn't understand. She left her homeland at age 5 and is from the Russian-speaking part of Ukraine, she explained. "My parents decided to teach us the most common of our two languages, which was Russian."

Shbat's mother stepped in to bridge the gap. "We sat down, and it was this surreal image of me being completely exhausted after a full day, on a double shot of espresso at 8:00 PM, and my mum is staring at this poorly scanned, smudged PDF with a magnifying glass. She's reading it to me very slowly, and I'm like, 'Mom can you hurry up?' And she's like, 'no I can't.' She was translating it from Ukrainian to Russian so I could translate it to English."

Shbat, her mother, and another medical oncologist labored through the patient's pathology reports, CT scans, and flow cytometry reports. Somewhere in the middle of translating the medical records "things got really obscure" because of the patient's extremely rare form of leukemia, which she declined to name out of concern it could identify him.

She had to turn to another friend with subspecialty expertise.

Victoria Korsos, MD, is an MUHC hematologist. "I don't speak the language, but I know the medicine," Korsos told Medscape Medical News. "Even if they translate the information, some highly specialized knowledge gets lost. Specialized details can be so important, like what a molecular test showed, or what the bone marrow looked like under the microscope ― and a person who is not a hematologist might not know what details are important ― there are so many.

"I have to rely on three types of labs report to do my job most of the time in Canada. This means that hematologists receiving these refugee patients have to rely on some sort of clinically assessed baseline and do their best," she said.

Shbat and her mother were stuck on some wording that is very specific to hematology, explained Korsos. From their description of the Ukrainian and Russian word, Korsos identified the English word as "sideroblast," which is a young red blood cell with abnormally high iron content. "She had to discuss it with her mom and come up with an educated guess of the term," explained Korsos.

"You can have sideroblasts in many conditions, both benign and malignant," she explained. "They are present in some forms of leukemia and are a diagnostic feature of a few subtypes of pre-leukemia you most often find in older adults but can rarely be seen in children also.

"So, when she called me, she literally asked, 'Is there a hematology term that is something like 'sidero' ― something like iron?' I'm sure you can imagine how many ways this can get lost in translation, as we are relying on extremely fragmented information to put the story together," Korsos commented.

Although the team wasn't questioning the diagnosis, which Shbat says was "clearly indicated and easily translatable" in the file, their quest was to translate the "critical pieces of raw diagnostic information" — following the breadcrumbs that led up to the diagnosis — so the London team could confirm and continue treatment.

On the basis of the word "sideroblast," Korsos and Shbat agreed that the diagnosis was one form of myeloid leukemia, or possibly a rare form for which the treatment is the same but the cure rates vary widely, from 50% and 90%.

The doubt sits uncomfortably with Korsos. "Is it possible that the word 'sideroblast' wasn't actually 'sideroblast'? Yes," she says, adding, "The devil is in the details" when it comes to cells under the microscope.

"Is it also possible that it was more relevant to the context of the report than we were able to make sense of? It is possible," Koros said.

They will likely never know how their distant patient fares, but there's no doubt that there is a long road ahead.

"A very young child, with a horrible, horrible diagnosis and an interruption in treatment at a very, very critical period," said Shbat. "That 24-hour delay where I couldn't get to it earlier.... I realize that was a critical time period, and I hope to God that kid is OK."

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.

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