Dr. Irena Shikova is a specialist obstetrician-gynecologist with over 10 years of experience. He graduated from the Medical University – Sofia in 2005. He acquired the specialty “Obstetrics and Gynecology” in 2013 after specialization at SBALAG “Mother’s Home”. After acquiring the specialty, he worked for two years at UMBALSM “N. I. Pirogov”. From 2016 to the present, Dr. Shikova has been part of the team of specialists at MC “Mother’s House”. He is a member of the Bulgarian Medical Union. He has participated in numerous national congresses and seminars in the specialty. – Dr. Shikova, what is cervical cancer and what are the reasons for its development? Cervical cancer is a malignant change in the cells of the cervix. It represents uncontrolled proliferation of these cells for various reasons. One of the most frequently associated causes is the so-called HPV virus, but it can be other viruses, inflammatory agents that provoke this abnormal growth. Most often, cervical cancer is associated with human papillomaviruses as infectious agents. HPV is a polytropic virus, it is not transmitted only sexually, it is also isolated in virgin women. Condoms are thought to not fully protect against HPV because areas that are not covered also carry this virus. There are more than 200 strains, though not all are linked to cervical cancer. Some of the strains of this virus are not high-risk for cervical cancer, but rather relate to warts, papillomas and others. High-risk for cervical cancer are 16, 18, 31, 33, 35, 51, 52 and they should be considered and we need to know if there is such a carrier in female patients. – Why is cervical cancer screening important? We believe that about two to three years after starting to have sex, the earliest changes in the cervix begin in case of HPV infection, the so-called. dysplasias develop within 5 to 7 years before progressing to invasive carcinoma. It is important to note that cervical cancer is favorable in that it develops slowly and we have the opportunity with this screening to prevent invasive carcinoma. Primary prevention of the cervix is ​​a regular annual pap smear of patients who have already had 2 or 3 years of sexual life. Colposcopy is an adjunct to the Pap smear because it captures areas that cannot be seen with the naked eye and complements the Pap smear. And if there are areas of concern, a biopsy is done after the colposcopy to make sure there is no incipient process or dysplasia or something more serious developing. As for women in the menopausal period, it is considered that they can do this preventive examination with Pap smear every 2 or 3 years. – Does cervical cancer have early symptoms? Unfortunately, there are no early symptoms. We consider that the symptoms, such as bleeding, a more peculiar mucus, a more peculiar smell, things are already advanced, not to mention the pronounced, visible lesions, the sore, which are very often late symptoms. Therefore, it is extremely important that patients are awarethat with Pap smear and colposcopy once a year, plus testing for high-risk HPV strains, primary prevention of cervical cancer is adequate, and the likelihood of developing invasive cervical carcinoma, which is life-threatening from a certain stage onwards, is maximally limited. – From what age can screening be done? For some time, the age group in which the first sexual contacts begin has fallen, there are even female patients who start having sex from the age of 13, which automatically makes them a vulnerable contingent for the transmission of infectious agents. So, if we talk about the age at which to start primary prevention – pap smear, colposcopy, we will take into account the age at which the patient begins to have sex. We also take into account the carrier or not of high-risk HPV viruses. – How is the carriage of high-risk viruses determined and what is the purpose of this test? It is established through a typical test, which is done with a cervical examination – with a pin, material is taken from the cervical canal, which is sent to a laboratory for a specific DNA examination. Our goal is to screen out those HPV viruses that are subject to more serious prevention. This should be mass screening in the country to screen out high-risk HPV carriers, as unfortunately it is impossible to cover the entire cohort of women once a year, so we will target those at higher risk. – Is the tendency to cervical cancer inherited? Heredity is not a factor in cervical cancer, rather we are interested in high-risk groups of patients with multiple partner changes and carriers of high-risk HPV strains. – At what age is the HPV vaccine administered and what should we know in this regard? The vaccine is given at the earliest at the age of 12 and is a preventive measure against cervical cancer. Putting it after the start of sexual life also makes sense, because the local immunity prepares itself to be at least more resistant to the most commonly diagnosed HPV viruses. A nine-valent vaccine is currently on the market. However, the vaccine against the HPV virus does not exempt from the preventive examination and Pap smear once a year. The nine-valent vaccine is covered by the health fund for girls up to the age of 16. – With early diagnosis of cervical cancer, is effective treatment possible? Cervical cancer is extremely favorable for early diagnosis. With oncoprophylaxis once a year, with high-quality cyto-smear collection and high-quality histopathological examination, I guarantee that there will not be a patient who was excited or was diagnosed at an inoperable stage. It takes between 5 and 7 years from the start of this process for a woman to become a life-threatening invasive carcinoma. – What is done in case of changes? When early changes up to the second degree are detected,most often they are burned by laser. When we have grade 3 dysplasia without invasive carcinoma, conization or the latest modern loop procedures are performed. With them, part of the cervix is ​​removed, but the patient can become pregnant and give birth. In an invasive process, a radical hysterectomy with lymphatic pelvic dissection is performed. This is an operation with a wider volume, in which not only the uterus and cervix are removed, but depending on the age of the woman and the stage of the cancer and the ovaries, as very often up to 1B, radiotherapy is additionally recommended. Chemotherapy is less often used in cervical cancer. It is possible for young women to save the ovaries. In view of the fact that many women get pregnant later, over 38-40 years, too, as long as the stage in which the cancer is diagnosed allows it. Cervical carcinomas are radiosensitive. A greater percentage of carcinoma of the cervix is ​​on the vaginal part of the cervix and about 10 percent of carcinomas are in the cervical canal, which are more difficult to diagnose and if there is any delay in diagnosis, they are more often caught later because as colposcopically it is difficult to see early. At the doctor’s discretion, after surgery for cervical cancer, immunohistochemistry can be done for higher certainty. – Are there statistics in Bulgaria on how many women are affected by cervical cancer? About 700 women in Bulgaria die from cervical cancer every year. And this number can be reduced, because the development of cervical cancer, unlike other malignant processes in the body, can be prevented. Affected patients are divided into several groups, one part are caught early, which are subject to more conservative surgical interventions, another part, in which radical surgery is required, and a third, in which radiotherapy is first carried out at the discretion of the oncologist, including one or two courses of chemotherapy in order to have surgery. The latter is required in advanced cases or in more severe cases in which the bladder and rectum are compressed and deformed. In order to avoid greater blood loss and greater trauma to the patient during surgery, it is recommended to undergo radiotherapy before surgery, rarely one or two courses of chemotherapy. Unfortunately, there is also a percentage of cases where women cannot be operated on or cannot survive the operation. – Do you have cases in which an irreversible process is established during an examination due to some vague complaints or a preventive examination? Such cases are rare in patients who regularly go for check-ups. In severe cases, usually the patients have not had an examination for about 10 years, and these are people with a lower social status. – Are there cases in which cervical cancer is diagnosed, and the woman does not have sex? There are cases of diagnosed cervical cancer in women who have never had sex. So it is not excluded that they carry the HPV virus.The juice also applies to patients with a more particular way of sexual hygiene. People are different in this regard. – What is the most important thing for women to know about the HPV virus? The HPV virus is epitheliotropic and there is no guarantee that after not having sex, the woman will not get infected with it by touch, contact – it even happens that the virus is isolated on the hands. Virgin women cannot be guaranteed that they cannot get cervical cancer. Regardless of whether or not you are still having sex, it is good to get a vaccine, as it does not give 100% insurance against the occurrence of cancer, but only a significant reduction in the risk of it. Patients should generally understand that there is no vaccine or drug that will insure against disease. A Pap smear should be done at a maximum of one and a half years, and a colposcopy at two, but the obstetrician-gynecologist can also recommend a shorter observation period. In cases of fluctuating cell results, a full HPV testing package should be done to determine whether the particular patient is at higher risk or can continue her prophylaxis as usual.