Cancer of the Cervix in Bulgaria: Epidemiology of a Crisis

Angel Yordanov, Mariela Vasileva-Slaveva, Noya Galai, David Faraggi, Milan Paul Kubelac, Irina Tripac-Iacovleva, Neville Calleja, Riccardo Di Fiore, Jean Calleja-Agius

Research output: Contribution to journalArticlepeer-review


Eastern Europe continues to have the highest rates of cancer of the uterine cervix (CUC) and human papillomavirus (HPV) infection in Europe. Aim: The aim of this study was to investigate CUC trends in Bulgaria in the context of a lack of a population-based screening program and a demographic crisis. Methodology: This was a retrospective study of 7861 CUC patients who were registered in the Bulgarian National Cancer Registry (BNCR) between 2013 and 2020 and followed up with until March 2022. We used descriptive statistics and modeling to assess temporal trends in new CUC incidence rates and identify factors associated with survival. Results: Bulgaria’s population has decreased by 11.5% between 2011 and 2021. The CUC incidence rate decreased from 29.5/100,000 in 2013 to 23.2/100,000 in 2020 but remains very high. The proportion of patients diagnosed in earlier stages of CUC has decreased over time. Up to 19% of patients with CUC in Bulgaria are diagnosed between the age of 35 and 44 years. The median survival was 101.5 months, with some improvement in later years (adjusted HR = 0.83 for 2017–2020). Conclusions: In countries with well-established population-based screening, CUC is nowadays considered a rare disease. However, it is not considered rare in Bulgaria. Population-based screening starting at an earlier age is the fastest way to improve outcomes.

Original languageEnglish
Article number318
JournalHealthcare (Switzerland)
Issue number3
StatePublished - 20 Jan 2023

Bibliographical note

Funding Information:
This research was funded by Bulgarian National Scientific Fund, project: MeMoMi: Mechanisms of Modulating the immune response in the tumor and its Microenvironment for development of prognostic groups and optimizing the treatment algorithm in patients with cancer of the uterine cervix. KП 06 H43 9. This paper is based upon work from COST Action CA18117—European network for Gynecological Rare Cancer research: From Concept to Cure (GYNOCARE), supported by COST (European Cooperation in Science and Technology). COST Action CA18117 is funding the open-access publication of this paper. COST (European Cooperation in Science and Technology) is a funding agency for research and innovation networks. COST Actions help connect research initiatives across Europe and beyond to enable scientists to grow their ideas by sharing them with their peers. This boosts their research, career, and innovation (, accessed date 30 November 2022).

Publisher Copyright:
© 2023 by the authors.


  • cancer of the uterine cervix
  • human papillomavirus (HPV)
  • screening programs
  • survival

ASJC Scopus subject areas

  • Leadership and Management
  • Health Policy
  • Health Informatics
  • Health Information Management


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