According to the latest data, more than 4200 new cases of lung cancer. Occurring in the first stages asymptomatically, usually this type of carcinoma is diagnosed in patients in advanced stage III or IV, when therapeutic options are more limited and the prognosis more severe. About the prevention and prevention of lung cancer, Prof. Dr. Dimitar Kostadinov, head of the Bronchology Department at UMBAL “St. Ivan Rilski”.

Prof.. Kostadinov, The World Health Organization warns of a continuous increase in lung cancer. What is the trend in Bulgaria??

In our country, there has been no oncology registry for a long time, and this makes our statistics very inaccurate, but from pooled data from individual centers, the digits move between 4200 and 4600 sick per year and the death rate is between 2700 to 3200. In our unit there are approx 800 the patient with proven lung cancer per year at over 2200 investigated. The tendency in our country is to increase this pathology, because we do not comply with regulations to reduce risk factors. For us you are taboo. Among the Americans, a decline in morbidity is observed until 45%, with female mortality falling even more significantly.

And what are the risk factors??

Smoking takes 30-35% of the risk factors, but the second most important is working or living in a harmful environment. They are described above 4800 harmful factors, between which talcum powder, asbestos, arsenic, nickel, chrome, polycyclic aromatic hydrocarbons, radioactive substances. We may no longer have production of such harmful raw materials, but the thermal power plants are working, everyone burns what they can, diesel particulate matter is also part of it… It's logical from there, air pollution is also a big risk factor.

Stress is a universal risk factor for all oncological diseases, because it is associated with a decrease in immunity. In lung cancer, it is among the leading risk factors.

Is prevention the most important thing?, to reverse this trend? What is being done in our country?, to reduce the incidence of this type of carcinoma?

Prevention is always the most important. We cannot change the tumor itself, therefore, all our efforts must be concentrated in prevention – stopping or reducing risk factors. This does not provide a guarantee, but reduces the likelihood of the disease occurring. We have a lack of effectiveness of primary prevention. for example, our anti-smoking law is one of the best in the world, but it is notorious, that it is not observed. We have the examples of a number of countries, which have an effective risk prevention policy, but we for some reason, we do not wish to apply them.

A screening program for lung cancer should be introduced in Bulgaria, which covers people with a high risk of developing the disease – over 55 years of age, long-term active smokers or such, exposed to harmful influences.

Prevention also includes changes in lifestyle and eating habits and timely treatment of precancerous conditions.

Can we talk about heredity in this disease? Do you have such cases in your practice??

Yes, categorically. About 5-10% of all cancers are hereditary. People, who have inherited the gene defects from their parents have a much higher chance of developing cancer and how the superimposition of additional risk factors can act as a trigger for this process, so reducing them can reduce the likelihood of manifestation. If we have to talk in percentages, the risk of lung cancer in people with a family history among first-degree relatives increases by approx 50% compared to these, without one. From 2 to 5 familially burdened individuals are times more likely to develop lung carcinoma.

Are there cases, in which lung cancer to “disguises” as another disease? What are the symptoms of this type of carcinoma??

There are three diseases, which can mask anything – thyrotoxicosis, tuberculosis and cancer. For example, difficulty walking from low back pain may be due to a neurological problem, but it could also be bone metastasis, but or paraneoplastic syndrome. That's why it's called, that “the mask” of these diseases is huge. Otherwise, the standard complaints are a specific cough, pneumonia, dyspnea, chest pain. Often our patients take such a cough as normal. “That's how I cough”, they say the only thing, which scares them, is the presence of blood in the sputum. It's not normal to heal 20 days of pneumonia without result and not to proceed to follow-up tests. There is a protocol, which advises in the absence of improvement after 20 days of treatment for pneumonia, bronchitis, HOBB etc., by the 30th day, invasive diagnostics should be started, to rule out carcinoma.

Barely 6 to 10% of the patients are without complaints at the time of establishing the diagnosis of lung cancer and this most often happens by chance, when an X-ray was taken on another occasion. This includes cases of early-stage cancer.

What are the most modern approaches to the treatment of this disease?

Diagnosed at an early stage, lung cancer is successfully treated in half of patients.

Operative treatment is standard. In his case, the novelties are related to mini-invasive surgery, incl. removal of lymph nodes. In lung cancer, it is very important to perform a good lymphatic dissection and to clear the lymph nodes as much as possible and at different levels. These can then be examined and thereby determine the spread of the process.

Robotic surgery also exists as an option, but it should be done by a highly experienced specialist and not commercially. This type of surgery is recommended for small 2-3 to 4 cm. tumors, which are difficult to access with the standard methodology.

The other method is radiotherapy. Modern equipment, which is already available in our country, is extremely gentle (stereotactic radiotherapy) and the possibilities with it are really great. We have a tremendous amount of experience with intra-radiation – a special catheter is placed inside, irradiated etc., but here we are talking about localized tumors. The cyber-knife is also a technique, which has high efficiency.

Of the drug therapies, chemotherapy remains the gold standard. There are three novelties in this area: target (aimed) therapy, which covers up to 12% from the patients, which are displayed for her, immunotherapy and personalized therapy. Immunotherapy is a double-edged sword, because there the patient's immunity collapses and his body may be exposed to a number of other inflammatory attacks.

Personalized therapy is the most advanced approach. With it, certain biomarkers are searched for in each patient, to ensure the most effective treatment. This therapy is just for a certain person, who has a precisely defined tumor. The drugs in this approach act in a targeted manner on the specific tumors. For this purpose, individual profiling must be done, genetic determination of cancer.

In Bulgaria, we also have lasers for palliative treatment, cryosurgery, different endobronchial methods for affecting the tumor, but they are very rarely applied.

And what is the role of genetics in determining treatment?

Basic in some cases. It's genetics, which based on certain characteristics (biomarkers) can determine the direction of therapy, its type and how effective it can be. In some cases, especially for non-small cell lung cancer, tests can be done for specific gene changes in cancer cells from the material, which is taken, with which therapies can be tested. Even if there is no cancer found, genetics can be used as a predictor.

Can we say, that in the future the effectiveness of therapies will increasingly depend on genetic research and the discovery of biomarkers?

Modern methods of diagnosis and treatment require more and more studies of genetic biomarkers. Along with optimizations in radiation therapy, endoscopic surgery and drug therapies, genetics is the other key player in the overall fight against lung cancer.


Prof.. Dr. Dimitar Kostadinov is MD, head of the Department of Pulmonary Diseases at the Faculty of Medicine of the Medical University – Sofia, from 2012 r. and head of the Bronchology Department of UMBAL “St. Ivan Rilski”.He graduated from MU – Sofia, through 1982 r. There are two majors – “Pneumology and Phthisiatry” and “ENT diseases”. Master of Health Management. Certified specialist in highly specialized activity “Bronchology”. He specialized in university hospitals “Pierre and Marie Curie” and “Denis Diderot” in Paris. A scientist, teacher, author of scientific publications, co-author in 3 monographs and 2 the textbook of internal medicine.