Prof. Dr. Asen Dudov is the head of the Medical Oncology Clinic at "Ajibadem City Clinic UMBAL Mladost" - Sofia and medical director of the medical facility from 2015 to the present. Before that, from 2011 to 2015, he was the head of the Medical Oncology Clinic at Tsaritsa Joanna Hospital - ISUL. From 1990 to 2011, he worked at "SBALOZ Sofia-city" as a medical oncologist (chemotherapist) - successively resident doctor, head of the chemotherapy department, director of the medical facility, associate professor.
For the period 2016-2017, he was also the chairman of the He alth Technology Assessment Commission at the Ministry of He alth.
Graduated from Medical Academy - Sofia in 1989. In 1998, he obtained a speci alty in Internal Medicine, Sofia Medical University. Two years later, he qualified in "He alth Management" - UNSS, and in 2001 he also graduated with a speci alty in oncology, VMI - Sofia. There are many specializations and studies abroad.
Cancer has now ranked on the same level as cardiovascular diseases in frequency and is expected to increase by 25% by 2030. This means that oncological diseases will become leading in terms of morbidity and mortality. At the same time, about 40% of cancer cases can be prevented through prevention. That is why the EU countries developed a European anti-cancer plan, financed with 4 billion euros.
On the eve of World Cancer Day - February 4, the Bulgarian Oncological Scientific Society updated the standards for diagnosis and treatment of oncological diseases and took decisive steps for Bulgaria's accession to the European Anti-Cancer Plan. On this occasion, we talk with Prof. Dr. Asen Dudov.
Prof. Dudov, what prompted the European Anti-Cancer Plan initiative?
- With the most benefits, he althcare assistance and the longest life expectancy in the modern world are the people of the "golden billion" of humanity - the population of Europe, to which we also fall, although with the lowest incomes and social structure. Precisely in the industrialized Western society there are two main causes of morbidity and mortality - cardiovascular and oncological diseases.
People have now learned to control their high blood pressure, hypertension drugs have become affordable both in terms of cost and convenience of taking. This significantly reduced the risk of heart attacks and strokes. People with cardiovascular disease are now living longer and therefore vascular disease has been controlled.
While the constant and smooth increase of cancer, especially with the aging of Europe's population, as well as the continuous chemicalization of the environment and the intense stressful lifestyle of the younger people, has led to a greater oncological incidence than cardiovascular.
What's more - Europe made a simple but important statistical analysis that showed that in the next 5 to 8 years, cancer will overtake vascular disease by about 10%, and by 2030, cancer will be the absolute "champion" among all disease morbidity and mortality across all ages. It has become crystal clear that serious measures must be taken by 2030 to help control cancers, as they did with cardiovascular diseases.
What is the European Anti-Cancer Plan itself essentially and how can Bulgaria get involved in it?
- The European Anti-Cancer Plan has four main pillars to control cancer
The first pillar is protection (prevention) and early detection of oncological diseases.
Conservation means controlling air pollution. Fine dust particles are the cause of lung cancer, pneumonia and other diseases. Another environmental factor can be controlled, human papillomavirus (HPV), for which there are vaccines.
HPV vaccination should not only be given to girls, but also to boys. Because there is transmission of the infection between both sexes, and in addition to cervical cancer, which women suffer from, carrying HPV leads to a higher incidence of malignant tumors of the head and neck in both sexes.
Another type of prevention is vaccination for the hepatitis B virus. It is an incurable disease and the most successful therapies can at most reduce the replication of the virus, but not completely clear it from the body. And long-term carriage of the hepatitis B virus leads to the development of cirrhosis of the liver and, accordingly, to primary cancer of this organ.
Cancer prevention can also be done through antibiotics. The eradication of the Helicobacter pylori bacterium is already done according to strictly validated methods. Gastroenterologists perform endoscopic examination under short anesthesia. While the patients sleep, the apparatus is entered, material is taken, helicobacter pylori overgrowth is proven, a course of antibiotics is administered, and the insidious further action of this bacterium, which can lead to stomach cancer, is stopped.
Conversely, when antibiotic therapy is not done, patients experience discomfort, heartburn, drink antacid drugs that suppress heartburn, but mask the ever-advancing cancer process. As the patients have no other complaints, we usually detect the advanced cancer of the stomach.
Prof. Dr. Asen Dudov
An element of cancer prevention is the necessary nutrition hygiene that every person should have. There are foods that cannot be said to be harmful, because that means claiming that the state allowed itself to register harmfulness instead of food. But there are foods that, if taken often and in large quantities, worsen he alth. These are fast foods, those with a lot of sugar, especially those containing glucose-fructose solutions, dyes, swelling agents, stabilizers, etc. They lead to fatty degeneration of the liver (steatosis), liver cancer, etc.
Smoking control definitely affects cancer incidence. We are one of the leading nations in smoking, which increases the risk not only of lung cancer, but also of cardiovascular events, especially myocardial infarction.
What is envisaged in the European Anti-Cancer Plan for the treatment of cancer?
- The second pillar of the plan is innovative diagnostics and treatment. They are together because innovative treatment cannot be done without modern diagnostics. Because it tells us more about the so-called biological locks or biomarkers in the cells of malignant tumors that allow us to conduct the most appropriate treatment. This is the so-called target, target or target treatment, as well as immuno-oncology and a number of other "smart" therapies. Knowing in which patients these therapies will work requires innovative diagnostics, usually genetic testing.
Innovative diagnostics are also needed to track the effect of treatment. When we use classical chemotherapy for three months, we do a control scan and we see that the tumor is shrinking. But if we apply immuno-oncology treatment and the control scan shows that the tumor is increasing, it means pseudo-progression. Immunocompetent cells are formed and accumulate on the tumor.
In reality, the tumor cells have largely disappeared, but the tumor has increased in size due to the accumulation of immunocompetent cells. However, this can only be understood by means of a positron emission tomography (PET-scanner), and the isotope with which it is made is also important. The most common method is with radioactive sugar, it can be done with gallium, which selectively sees prostate cancer down to its details.
Neuroendocrine tumors are also examined with gallium, even determining whether there are growth hormone receptors on their surface. They are the keys to a physiological and easy-to-perform treatment, which is a single intramuscular injection of somatostatin hormone. It completely blocks the disease without the patient experiencing adverse drug reactions and complications.
What is the third pillar of the anti-cancer plan?
- It is extremely important because it is related to the quality of life of patients. First of all, the quality of life of those undergoing treatment is monitored. They often need additional medical care, outside of specialized oncology treatment. It is important how these patients are covered by the he alth care system, how they are protected legally so that they are not released from work just when they need income to be treated and fed well. Because most employers are not very happy to have an employee who often has to be absent for treatment, or who is not able to work at certain times.
The third pillar of the plan also includes taking care of the quality of life of those patients who have not been able to overcome the disease. They should live comfortably, without pain, without disturbances in urination, without difficulties in eating. In order to eat normally, they can have stomas put on them - devices that are attached to the gastroscopes, instead of making holes in the stomach like before.
It is important that these patients end their lives in humane, normal conditions. These patients are usually bedridden, require assisted toileting and feeding, need analgesia, treatment of anti-decubitus wounds, replacement of ostomas if the anus preter or ureters are removed, care of the tracheostomy if removed. This care in our country is not regulated at all and everything depends on the patient's relatives. There is only one clinical pathway for 10 – 15 days of palliative treatment, which is absolutely insufficient.
It is unworthy even to speak of real palliative care being carried out. Realistically, there should be real hospices - medical facilities that allow people who have paid their insurance all their lives to end their lives with dignity. Let their loved ones help them, let them be by their side, but also have the opportunity to go home and sleep for a few hours. In addition, there are elderly people who are unable to provide adequate palliative care for their sick partners.
How will all these anti-cancer measures be implemented in practice?
- The fourth pillar of the anti-cancer plan is intended for this. Funding is provided for the implementation of these measures in the he althcare systems of the EU member states. At the same time, funds are allocated to equalize standards in individual countries.
Funds are planned for the provision of equipment, as well as the training of doctors to perform innovative diagnostics. There will be training in specific hybrid methods, similar to the PET-scanner, which represent the aerobatics through which we can control the oncological incidence.
Just a week ago we updated the national standards for drug treatment of cancer patients. And notice – we've made 198 adjustments to standards that have come into force in the past 2021. Imagine at what pace medical oncology is developing, since 198 corrections are required in drug treatment alone in one year.
This is due to new indications of the drugs, the use of combined regimens of chemotherapy and immunotherapy, which in clinical trials proved a fantastic result in certain groups of patients and given histological types of cancer, compared to immunotherapy treatment alone. We have one final revision of the standards coming up and in no more than two weeks they will be available to all colleagues.
Can new diagnostic methods and therapies become fully accessible to Bulgarian patients from the funding pledged in the European Anti-Cancer Plan?
- In order to have modern treatment at all, we must have all aspects of the anti-cancer plan. This money is also for Europe to include us in the common group of partners to have an equal chance for diagnosis and treatment of patients. There is no shame in saying that we are at a disadvantage, as part of the funds are earmarked for EU member countries that are disadvantaged in some aspects of cancer treatment.
It would rather be terrible if we do not now actively apply to eliminate these discrepancies, if we do not show national responsibility. If we fail to get involved in this plan, where everything is written, prepared and financed for us, and we just have to make an effort to implement it in the country, it would speak very badly for us. The implementation of the anti-cancer plan in our country is somewhat a matter of instinct for self-preservation.
Which institutions depend on the implementation of the anti-cancer plan in our country and what should be done?
- It depends on the Ministry of He alth. We did our best and on February 4 - World Cancer Day, we organized a large national meeting of the experts whom the Bulgarian Oncology Society chose to lead in this process.
We all united, created a National Oncology Alliance and sent out experts who, within 30 days (we have no time to procrastinate, deadlines are running out) must propose a program to address to the European Union and to the European Commission, to the European he alth commissioner to get their recommendations. And then the Ministry of He alth should start actively working on the implementation of the anti-cancer plan in our country.
Because without the state, without a national policy, it is an illusion that this can happen. I heard, unfortunately, statements from colleagues in the public space that the European Anti-Cancer Plan was the work of non-governmental organizations. Taking such a position is criminal. In this way, we deprive ourselves of the opportunity to be a truly equal European partner in the fight against cancer.
We signed a joint document with the Bulgarian Medical Union and a number of other professional organizations in order to help the state implement this national policy, so that the European Anti-Cancer Plan can also be implemented in our country.
There is no screening in Bulgaria
“Screening should be done among risk groups of the population. Unfortunately, there is no cancer screening in Bulgaria. This is our shameful secret, which must be told clearly to Europe, so that we can introduce the necessary studies of the risk age groups in the search for certain types of cancer.
This is the only way to reduce the incidence of certain oncological locations, such as breast cancer and cervical cancer. Cervical cancer screening has decades of experience in Western Europe. The Scandinavian countries were among the first to start cervical screening half a century ago. If a woman dies of cervical cancer, it is not only his fault, but also the lack of early screening.
Among the new screenings, which are expected to become standard in certain population groups in Europe within 3-4 years, is the low-dose lung scan to look for early forms of cancer. Because the early forms are much easier to treat. Among the new screenings is also the conduct of gastroscopies - an examination of the stomach for the early detection of stomach cancer.
Ten years ago, this location of cancer had started to decrease, amazingly in the background of all other increasing types of cancer. But in the last 5-6 years, the incidence of stomach cancer has increased extremely rapidly in Europe and North America due to the use of chemical products for food. Some of them could hardly be called food because they are entirely composed of artificial substances, swelling agents, dyes, flavors and have nothing to do with natural foods.
Prostate cancer screening (via tumor markers in venous blood) should also be introduced as screening among at-risk age groups. Years ago, there was a nationwide screening of men for prostate cancer in the US that led to overtreatment.
However, I emphasize that in this particular location of the cancer, universal screening is not necessary because some patients never have their cancer progress. It is usually discovered incidentally, is small tumors in relatively old men and allows, when the tumor marker is only slightly increased, only to be observed.
Many of these men require no treatment at all. However, this is far from the case in young men, in whom even small deviations of the prostate-specific antigen may be a signal of aggressively developing prostate cancer. We need to be active in prostate cancer screening programs in young men (30-50 years) because they have a worse prognosis.
The European anti-cancer plan also foresees smaller screenings for rarer cancer locations, such as some types of skin carcinomas - malignant melanoma, squamous skin cancer, basal cell tumors. Such a screening program operates in Switzerland. There, for 15 years now, every formation on the skin has been examined, removed, and treated. In this way, the Swiss reduced the incidence of malignant melanoma by 25%, explained the top specialist.