Prof.. Dr. Assen Dudov, dm is the head of the Clinic of Medical Oncology at “Acibadem City Clinic UMBAL Mladost”, medical director of the medical institution and chairman of the Bulgarian Oncological Scientific Society.
He specializes in Saint John’s College, University of Oxford, Great Britain; Institut Jules Bordet, Belgium; Thorax Clinic Heidelberg, Germany; Gustave Rossy Institute, France; San Francisco Comprehensive Cancer Center, USA; Harvard Medical School, USA; Massachussetts General Hospital, USA; MD Anderson Cancer Center, USA.
Prof.. Dudov is a member of the European Organization for Research and Treatment of Cancer (EORTC); European Medical Oncology Association (ESMO); European Organization for Research and Treatment of Neuroendocrine Tumors (ENETS); American Cancer Research Association (AACR). His interests are focused on the treatment of solid tumors and in particular approaches to overcoming drug resistance.. He is also a specialist in the field of targeted therapy for breast cancer, neuroendocrine tumors of the colon and rectum, kidney and prostate.
In recent years, new procedures have been introduced to treat patients, new drugs were reimbursed, whether the oncological care has changed and in what aspect?
I have no idea what is going on. There are exceptions to all the rules introduced, each hospital makes some oncology commissions, tons of paper with patient documentation are forwarded – half the documents remained somewhere, another would give them, begins a digging and searching for what to do with patient X or Y..
A few years ago, a crazy and extremely vicious procedure was introduced, according to which the treatment of the patients must be determined according to documents. The error in checking the boxes in the documentation is absolutely technically possible and this can predetermine who lives and who dies.. In addition, patients are sent with incomplete documentation. For example, a patient is sent for prophylactic chemotherapy, radically operated on for colon cancer, but it is not recorded anywhere, that there are liver metastases. Or a patient with breast cancer comes, on which the receptors are not made, no one tells her, that such research is needed, and we don't know if the cancer is HER-positive or not. What decision to take the commission, since the treatment in the two cases is different? This is not medicine, this is not oncology.
Doing all this, we have achieved colossal savings over 1 million. BGN, no one said “thanks to”, we are used to. It was talked about for a long time, that hospitals will be stimulated in some way for this, for example with consumables, with which we save medicine. It turns out so, that hospitals, who have worked with 50% loss of drugs, and we, which in an effort to group the sick, we have reached the floor 5%, which is above all European and world standards, we are on the same level in the eyes of the health insurance fund. There is currently no other medical institution in Bulgaria, which is so manic to save the state's resources. As a result, nothing happens. There is no incentive, that it works that way.
More than 20 years saved big business, associated with other diseases, which should not fall within the scope of public attention, because they cost much more. There are chronic diseases, for which for 40-50 years a colossal resource is allocated, oncology is a drop compared to it. But when a new minister or manager of the health insurance fund takes office, it always starts with how much money oncology spends, what crooks and murderers we are. Here are the events they show, that we have reached the bottom of sinking into our healthcare. It is broken, it is brought to its knees and is the most absurd, that now, when we have the latest technology, with the most innovative treatment methods, when there is also purchased equipment, which gives incredible opportunities, aligning us in practice with European and at many times world standards of diagnosis and treatment, we find ourselves facing purely organizational madness from people, who do not want or in my opinion, I say it quite responsibly and I would repeat it, they may not be able to mentally grasp some of the processes in health care and thus create chaos, which interferes with the treatment of the sick. for example – fixing the sick as many as the beds in the hospital. If someone breaks their leg in front of the hospital, we have to leave him on the street, because the system electronically does not allow us to accept it at full employment? We have patients with complications from therapy, which must be taken extraordinarily, how to proceed with them? It turns out, that when something has to be paid extra, and the NHIF does not cover it, so that there is no social tension, the doctors and staff are left to talk to the patient about how to pay for the staples for the operation. And no one says it every day in public, that to run the healthcare machine, are not sufficient 4.5 billion. BGN. from the health insurance fund, and patients pay even more. These are payments, which must be settled, structured and come to light, dressed in clear rules with a long horizon of action. It is not far-sighted to calculate what will happen by the end of the year, we need to plan within 10 years. This requires political understanding and the creation of an anti-cancer plan, covering every aspect of cancer treatment.
What should be the anti-cancer plan of Bulgaria?
Let's start from the beginning – it is no longer clear to anyone when we are talking about screening, what are the prevention and early diagnosis of cancer, which localizations are subject to this. We just forgot. It is no coincidence that it is said, that when a woman dies from cervical cancer, it's not just cancer that's to blame. Decades of screening for the disease in the Nordic countries have halved, and currently up to 1/3 the disease.
In Bulgaria, some of the ministry's teams thought of screening, handed out folding donkeys to GPs, which they pushed under the desks. Then it was understood, that patients will not be diagnosed in this way, and turned to gynecologists. There is also a problem there, because in addition to the gynecological examination, an adequate cytosmear must be performed, which requires a pathologist. So we have virtually no screening. It's all a hanging tragedy, which must be covered in a common project, in general, to give perspective to the various ministries, because not only health is involved in the process of fighting cancer, of the legislature, of specialists. Everyone needs to know what needs to be done, what is the step, where they are at the moment, what is the next goal, because there is no plan, is there no description, there is no funding for any program.
The incidence is invariably increasing worldwide. The good news is, that patients now live longer, some of them are cured, but this is at the cost of adequate treatment. There is no way a person can be treated adequately, if there is regulatory chaos, which unfortunately is deepening. It is constantly repeated, that there were many oncologists in Bulgaria. In the industrial world, including in Bulgaria, people suffer mainly from two types of diseases – cardiovascular and cerebrovascular disease and cancer. Very few die from infectious and various diseases, as well as in accidents. Since we have so many patients and the medical facilities are full of them, why we continue to discuss their number.
It would take a group of experts, supported by political will, to develop an anti-cancer plan, covering all aspects of treatment, of the interaction between the medical establishments, t.nar. so far and has not been created, and impossible, and unnecessary complexity, in which to cut in one place, to irradiate in one place, chemotherapy and follow-up of patients in one place.
I do not think, that we should have huge specialized hospitals just for cancer cases. We are a small country, which is not difficult to cross in one day and if a person wants to get qualified help, must have qualified, well-equipped and really working medical oncologies, qualified, equipped and really working radiotherapy and surgeries with the most modern equipment for robotic and laparoscopic operations. It is not necessary to gather all this in one place. Hospices all over the world are separated from hospitals and are nice buildings, in which patients are adequately cared for, who need, and it is quite wrong to understand, that they are only for cancer patients, without taking into account, that we need to help people with dementia, with advanced Alzheimer's, with very advanced diabetes, which leads to amputated limbs.
IN USA, who manage health care costs in the best way, the oncology network has organized the so-called. comprehensive cancer centers. This simply means not gathering all the specialists in one building, and to unite several medical establishments and to operate on the patients in one of them, in the other to perform radiation therapy or chemotherapy. Such a center operates, for example, in San Francisco and is located in several hospitals, as two of them are outside the city. I think so, that at every stage the treatment must be so organized, that the best specialists take care of the patient to the fullest.
Given the lack of up-to-date information in the cancer registry, how many patients have cancer, how much they are actively treated, according to you?
This is the other tragic moment. There is practically no register, to give us information about the exact number of patients, for stages, for histology, for different characteristics of the tumor, what is he like – low or highly differentiated, what sharing potential it has, receptors. And then, when the registry opens, each financier could be shown the real statistics and told how much the treatment of each individual patient costs and then it is clearly funded or it is said “sorry, we cannot provide treatment for these people”. This is an honest approach. The political approach, of course, is another – no register, not to know who is sick of what and who is currently being treated, but let's say, that “we give” 4.5 billion. BGN for healthcare and our priorities are campaign – today a children's hospital, tomorrow nursing home, but never fully funded. Because the confused legal framework does not allow the funds to reach the pediatricians or for the salaries of the nurses. The law allows directors to set salaries, after paying off their debts first. Hospitals are usually in debt and this possibility is unfair to the team, reduces the quality, reduces the correctness of treatment and leads to compromises – the most unpleasant of which is to bend the arms of doctors not to use some expensive therapies for economic reasons. Yes, but economic reasons cannot be leading, when it comes to human life. Which is more important – a person to recover and be for many years with his loved ones and full in society or to die, to reduce the red minus in the balance of the hospital? This is vulgar, this, in my opinion, borders on genocide.
A product of systemic degradation in medicine is the deliberate planting of a negative attitude towards the medical community..
Each of us remembers the insinuations about the killed baby in Gorna Oryahovitsa. The trial is over, colleagues were acquitted, did anyone understand it? Steps need to be taken to regulate relations more strictly. This, that assault on a medic is classified as a crime, is an initial step, but the relationship between doctors and patients must be very strictly channeled, because aggression in the behavior of patients and their loved ones begins to cross any boundaries. You can't talk to doctors with a clear language of hatred, medics cannot be resident at work, cannot be offended, and this is an attitude, which we face every day.
Medicine is not just regulating which drug to expire for how long or which operation with which device or method to perform, medicine is a bunch of rules, which are missing – how to come the patient, how to make a consultation, what should be the order, by which this should happen, so that the whole ensemble can work. There is no way to take one step out of the whole context.
In Bulgaria there is perfect access to specialists, probably the best access in the world. Everyone, who has opened the door to the best in a particular specialty, can enter inside by force, with a weapon, with crying or as you choose and will receive counseling. And there are no rules and regulations, to be described, the procedure “you have to accept us, because we have a big problem” leads to this, that the doctor changes his overall schedule and may not be completely helpful for this one either, who entered the office without an hour, nor for the other patients, with whom he went on a visit, nor for the doctor himself. Doctors are human beings, with their positive and negative emotions, with their blood and diabetes and have some limit, which must be complied with.
It is difficult to fight the lack of faith in healing every day, with what you read on the internet, with threats, that now we will call on TV or to someone.
You mentioned the lack of trust, how often do you encounter self-medication and self-diagnosis on the Internet, with the heyday of “the alternative” medicine?
Unfortunately, patients come to us every day, spent colossal sums on herbs, for some magical compounds, for magic, for unclear what supposedly medicinal compounds, arrived from abroad through black channels, for alternative healers without medical education. The trade in food supplements is also becoming extremely vulgar. Yes, probiotics, for example, have a role to play, if a person has gastrointestinal disorders, but have nothing to do with cancer, whether offered live, liquid or whatever.
Our treatment is at fixed intervals from 14 or 20 days and often happens that way, that patients do not have money for a train ticket, because they have literally ruined themselves financially for mushrooms, all kinds of eagle feces and supplements, which supposedly cure cancer. Not to mention the sale of housing, to fund a trip to shamans abroad.
At the same time, oncology is one of the most advanced and rapidly evolving fields of medicine…
Yes, now, through 2020 g., when the personalization of cancer treatment is possible and after the targeted therapies the era of immuno-oncological treatment occurs. We have reached a very interesting moment, which must be very well thought out by the financiers. It is about the possibility of total sequencing of the tumor – a particle of it is released into an apparatus and it detects all genetic defects and those, for which there are drugs, and such, for which there is none. And the issue is on the agenda – if we have drugs for these genetic defects, but they are registered for the treatment of other cancers, can we use them. If we do that now, it is an illicit practice, which is called off-label use, which is outside the approved characteristics of the drug
What needs to happen, so that information on available therapies can be updated in real time?
To keep up with the modern world, not only is faster approval needed for new treatment, and in-depth cooperation with international institutions – European Medical Oncology Association, International Union Against Cancer, American Clinical Oncology Association, world and European patient organizations. Somehow we are not on the map for them. Yes, they are coming, they ask us for data on the treatment of patients, we cannot give them, because we have no statistics, we explain clumsy things about how the specialty develops, we do not have a representative office of these organizations in Bulgaria and no one bends to represent them. Even with the World Health Organization, he only contacts the Ministry of Health.
We have a concrete example of speed in medicine. China has made us witness things, which have not happened in human history – under 30 days for isolation of the micro-organism, causing coronavirus infection. This is practically a scientific discovery. Then they built a hospital for 1000 people for five days. These are examples, which show what the organization means, of course, and the resource, in healthcare.
How in this document could be solved the key issue with the deficit in your specialty, how many medical oncologists do you work in Bulgaria?
We are around 50 souls. We are trying to overcome the negative image of medicine. Young people no longer want to study for six years, to complete medicine, then specialize five more, and then acquire a high qualification. Each of them would like to be realized much earlier, than on 40 years. Opportunities for career development, the ridiculous pay, often the conditions as a material base repel young people. Top equipment for millions was bought at structural hospitals in the country, which is mounted in a hall, whose tiles fall from the wall.
You need a strong hand, which to decide, that only these medical establishments will remain operational, who can meet certain criteria.