Dr. Rositsa Krasteva graduated from the Medical University in Sofia in 1994. She has two specialties – internal medicine (2001) and oncology (2005). She specialized in university hospitals in Turin (Italy), Athens (Greece), Munich (Germany), Basel (Switzerland). She worked in the medical oncology clinics of the “Tsaritsa Joanna – ISUL” UMBAL (1995 – 2012), the “Serdika” UMBAL (2013 – 2014) and since 2015 has been the head of the medical oncology department at the Oncology Center at the “Uni Hospital” UMBAL in Panagyurishte. Since 2019, Dr. Krasteva heads the entire oncology center at Uni Hospital, which includes the departments of medical oncology, radiation therapy and nuclear medicine. Dr. Krasteva is a laureate of the St. Ivan Rilski Foundation’s prestigious annual award for contribution to healthcare for 2017 in the Oncology category. – Dr. Krasteva, is the incidence of breast cancer increasing? According to Globocan, the incidence of breast cancer in Bulgaria in 2020 was 4,061 people or 11.1%, and the mortality rate was 1,533 or 9%. In 2019, the US National Cancer Center published that the death rate from malignant diseases in the world decreased to 29%. Death rates from lung cancer and breast cancer have decreased most sharply. In Bulgaria, the death rate from breast cancer is also decreasing, but there is no improvement in lung cancer. The incidence of lung cancer for the same period in Bulgaria was 4,300 people or 11.8%, and the death rate – 3,609 people or 18.5%. The reason we diagnose more cases of advanced breast cancer and other malignant diseases in Bulgaria is that in our country only preventive examinations are done, while in other countries mandatory screening is done. With screening, the disease can be detected at an early stage, and survival in stages 1 and 2 is greater. With the possibilities of new therapies – immunotherapy, targeted therapy and a combination of chemotherapy and targeted therapy – it is possible to control even stage four disease and for patients to live more than five years. That is exactly why the mortality rate from breast cancer tends to decrease in our country as well. – What is the diagnostic path of a patient with breast cancer? Cancer is a special disease that gives symptoms very late. If we wait for a symptom to appear first that prompts us to go to the doctor, we are already too late. In case of breast cancer, women themselves feel a lump in their breast or in the axillary pit and then go for an examination. An ultrasound or mammogram should be done and a biopsy, that is, material from the tumor, should be taken to understand the biology of the tumor. Then staging is done – we determine how far the disease has spread. For this purpose, we may use a contrast scanner, an MRI or a PET scanner. In fact, we need to find out if the tumor is only in the breast and in the lymph nodes, or if it has spread to other organs. This is extremely important because the approach is different. If the disease is limited to the breast only,it is possible to start with the surgical method – to remove the tumor. If the tumor is small – about 1 cm – but has metastasized in the axilla, while being hormone sensitive and HER-positive or triple-negative, it is better to start with systemic treatment. It includes both chemotherapy and targeted therapy. In the case of triple-negative cancer, when it is locally advanced, immunotherapy can be added. The combination of chemotherapy with immunotherapy, with subsequent immunotherapy after surgery is the successful treatment, these patients can be cured. If the tumor has spread and affected other organs, the choice for this patient is systemic treatment. This means chemo-, immuno- or targeted therapy. So diagnosis necessarily includes biopsy and staging of the cancer. Only then is a decision made about what treatment to start with. – Explain what is so called triple negative breast cancer? In triple-negative breast cancer, the tumor is negative for the estrogen receptor, the progesterone receptor, and the HER2 receptor. This means that hormonal treatment will not lead to success and we do not expect a good response with targeted therapy. This tumor is extremely aggressive and has a more particular course of development. Even if the tumor is small (less than 2 cm), it is better to start with preoperative treatment, which by now is chemotherapy. The prognosis is better when, through preoperative chemotherapy, the tumor shrinks during the course of treatment, and in some patients it even melts and a complete remission is reached. If we start with surgical treatment and remove the tumor, we will not be sure that the drugs will work. The results of clinical trials in triple-negative breast cancer in the neoadjuvant and adjuvant aspects with a combination of chemotherapy and immunotherapy showed extremely good results. – What is the most important condition for successful breast cancer treatment? Nowadays, cancer patients can be cured. The first and most important condition for successful treatment is to know the biology and characteristics of the tumor, that is, what kind of cancer it is and how widespread it is. Additionally, through molecular diagnostics, we can detect mutations or abnormalities in the tumor, thus entering personalized medicine. Molecular (genetic) diagnostics is also done in Bulgaria. – What is the multidisciplinary approach in diagnosis and treatment and is it applied everywhere in Bulgaria? I cannot say whether it is applied everywhere, but in the work of our oncology center we apply this approach and personalize the treatment of patients. A multidisciplinary approach means that a breast cancer patient is cared for by several specialists. These are the surgeon, the pathologist, the medical oncologist, the radiation therapist, the radiologist, the clinical psychologist. In many places around the world there is also a so-called breast unit, in which only breast cancer is treated and all specialists are in one place,thus all multidisciplinary patient care occurs in one location. All this happens in medical facilities that have the appropriate departments. In Bulgaria, each patient is discussed at a Tumor Board, where a decision is made on the therapeutic tactics that will be applied to him. The decisions made are then explained and discussed with the patient. – What are the innovations in the treatment of breast cancer? These are the possibilities that target therapy and immunotherapy provide. HER2-positive cancer has always been associated with an aggressive course and worse prognosis, but thanks to targeted therapy in the last 10 years, the course of this disease has changed. Triple-negative breast cancer also has a poor prognosis, and we await the possibilities of immunotherapy to change the course of this disease. – What do you advise women about breast cancer prevention? I recommend and insist that at least once a year women over 40 have an ultrasound examination of the breasts and a gynecological examination. Even if their professional societies do not organize it, let them have this prevention as their commitment. I also advise them to see doctors who specialize in the treatment of breast cancer. I hope that breast cancer screening will be introduced in Bulgaria soon, and then things will be much easier for both doctors and patients. – What should make young women between 20 and 30 years old go for a preventive examination? If there is a mother, aunt, grandmother with breast cancer, ovarian cancer or colon cancer in their family, that is, they have a hereditary burden, my advice is to have an ultrasound examination of the breast, a general blood test and an ultrasound examination of the abdominal organs once a year. This way they will have the peace of mind that this check has been done and that they have taken responsibility for their own health.I hope that breast cancer screening will be introduced in Bulgaria soon, and then things will be much easier for both doctors and patients. – What should make young women between 20 and 30 years old go for a preventive examination? If there is a mother, aunt, grandmother with breast cancer, ovarian cancer or colon cancer in their family, that is, they have a hereditary burden, my advice is to have an ultrasound examination of the breast, a general blood test and an ultrasound examination of the abdominal organs once a year. This way they will have the peace of mind that this check has been done and that they have taken responsibility for their own health.I hope that breast cancer screening will be introduced in Bulgaria soon, and then things will be much easier for both doctors and patients. – What should make young women between 20 and 30 years old go for a preventive examination? If there is a mother, aunt, grandmother with breast cancer, ovarian cancer or colon cancer in their family, that is, they have a hereditary burden, my advice is to have an ultrasound examination of the breast, a general blood test and an ultrasound examination of the abdominal organs once a year. This way they will have the peace of mind that this check has been done and that they have taken responsibility for their own health.