Assoc. Dr. Iliya Karagyozov is a specialist obstetrician-gynecologist and abdominal surgeon in Sofia with over 25 years of experience. He is the chairman of the Bulgarian Oncogynecology Association. A priority in his professional activity is the early diagnosis of oncological diseases of the female reproductive system, radical oncogynecological and extended pelvic surgery. In 2007, for the first time in the country, he introduced laser excision surgery in outpatient settings for precancerous conditions of the female genital system (laser conization). In 2020, he headed the VITA Dysplasia Center – the country’s first specialized structure for early diagnosis and treatment of genital precancerous changes of the female reproductive system. Leads postgraduate courses in colposcopy and treatment of female genital pre-cancer. We talk to Prof. Karagyozov on the occasion of Cervical Cancer Prevention Week (January 23-27). – Prof. Karagyozov, what is the cause of cervical cancer? The main cause of cervical cancer is a persistent human papillomavirus (HPV) infection in the genital epithelium. Papillomavirus types 16 and 18 are carcinogenic, as well as a few more, called high-risk types. They cause cellular changes called dysplasias. Carcinoma starts from these dysplasias, or in other words precancerous conditions. – How many women in our country are diagnosed with HPV each year and at what stage of the disease? It is difficult to say precisely because the national cancer registry is not fully operational. But it can be said that about 1,200 women are diagnosed with cervical cancer a year. Of these, about 65% are in the first and second stages, about 30% are in the third and fourth stages, and only about 5% are diagnosed with precancerous changes – these are dysplasias. – What other diseases does HPV cause besides cervical cancer? Diseases caused by HPV affect both sexes. In women, in addition to cervical cancer, there is a definite connection with HPV in vaginal and vulva cancer – about 70% of them are caused by the same high-risk papillomaviruses. In both women and men, high-risk HPV causes 90% of anal cancers and at least 60% of penile cancers in men. 75% of throat cancer in both sexes is associated with carriage and infection of a high-risk type of papillomavirus. There is also initial evidence that HPV may also cause lung cancer. – Is it possible to prevent cervical cancer and all other diseases caused by HPV and how? It is possible. Organized action is needed in three directions that, working continuously and in sync, lead to a gradual reduction and even disappearance of HPV-related carcinomas. The first guideline is primary prevention with the HPV vaccine, which should optimally cover the target groups. The second direction is effective population screening with a highly specific test and the third direction is the early diagnosis and treatment of the detected precancerous changes from which cervical cancer starts.For primary prevention with a vaccine in Bulgaria, the target group is girls between the ages of 9 and 13 who have not yet started sexual life. In Europe, boys are also vaccinated because, in addition to suffering, they are also carriers of papilloma viruses. In practice, the existing vaccine program in our country has extremely low coverage, and population screening is lacking. The latest figures cited for the country showed vaccine coverage below 5%. The state has allocated funds for a national program, but parents either do not know about it or refuse to vaccinate their children. – Explain what the HPV vaccine is and why people don’t need to be afraid? Vaccines are harmless and extremely effective. They have been monitored for many years and have shown no serious side effects, unlike those of vaccines for any other diseases that are used in the world. Numerous studies have proven the effectiveness of vaccines. Applied optimally and on time, they certainly reduce the risk of developing precancerous changes and cancer in a huge percentage of cases. In countries where such a vaccination program operates with the necessary coverage and in sync with an effective screening program, there is already talk of virtually eradicating HPV-related cancer as a socially significant disease. – Why is Bulgaria in the 3rd place in terms of HPV incidence and in the 4th place in terms of mortality in Europe? Broadly speaking, there are three reasons. The first is paradoxical – we can vaccinate our children for free, but for various reasons we do not do it, i.e. we have a national vaccination program, but we do not have optimal vaccine coverage. The second reason is the lack of workable population screening for cervical cancer and other HPV-related diseases, ie prevention is left in the hands of patients. The purpose of mass screening is to find among the many normal results the few questionable ones and refer them to gynecologists for clarification. The third reason lies in the lack of a Register of specialized medical and diagnostic structures, distributed on a territorial basis, where women can seek help. The combination of these reasons ultimately determines our place in the negative statistics. – Are there tests for oncogenic HPV? There are enough tests – both old and new. Particularly useful are those that determine not only the carrier of the highest-risk types, but also provide the opportunity to determine the individual risk of developing dysplasia, the so-called. triage. This helps gynecologists a lot in choosing medical behavior. Unfortunately, the tests are at the expense of the patients. There are not many women who would pay, for example, BGN 100 for such a test, and for now we apply it selectively, while it is routinely applied around the world for screening and triage. – What are the practices abroad that achieve the necessary vaccine coverage? Good vaccine coverage in European countries and around the world where such programs exist is mainly due to people’s trust in medicine and in science.Because vaccines are not from yesterday. There is a huge experience with them and the application of many vaccines has led to the eradication of extremely serious diseases in the history of mankind. In countries that have achieved optimal vaccine coverage, campaigns are regularly held to inform parents why it is important to vaccinate their children against human papillomaviruses, along with all the mandatory vaccines in the immunization schedule, and to convince them that doing so is beneficial for their children’s health . Parents should be aware that if they decide not to vaccinate their children, it may cost them their health and life years from now, and that the responsibility for this will be theirs. – What other preventive measures are used in developed countries? Through various forms of school education with the participation of specialists and parents, children are introduced to the biology of human sexuality, learn the rules of responsible sexual behavior, details of intimate and sexual hygiene, sexually transmitted diseases and ways to protect against them. Information campaigns on these problems in society should not be spontaneous and sporadic, but regular and permanent, in order to have a long-lasting positive effect. And despite everything, the family environment and parents play a major role in this sense. Bulgaria should soon adopt a National Anti-Cancer Plan also regarding HPV-related pathology. It envisages that vaccine coverage will reach 90%, that screening will cover at least 70% of women in the country and that 90% of women diagnosed with pre-cancerous changes and cancer will be treated in a timely and quality manner. It won’t be quick and easy, but the effort from all of us is worth it. I sincerely hope this actually happens.Bulgaria should soon adopt a National Anti-Cancer Plan also regarding HPV-related pathology. It envisages that vaccine coverage will reach 90%, that screening will cover at least 70% of women in the country and that 90% of women diagnosed with pre-cancerous changes and cancer will be treated in a timely and quality manner. It won’t be quick and easy, but the effort from all of us is worth it. I sincerely hope this actually happens.Bulgaria should soon adopt a National Anti-Cancer Plan also regarding HPV-related pathology. It envisages that vaccine coverage will reach 90%, that screening will cover at least 70% of women in the country and that 90% of women diagnosed with pre-cancerous changes and cancer will be treated in a timely and quality manner. It won’t be quick and easy, but the effort from all of us is worth it. I sincerely hope this actually happens.