Preventable, Yet Unprevented: The Cervical Cancer Screening Landscape in Eastern Europe and Bulgaria

Cervical cancer is one of the most preventable malignancies, yet disparities in survival remain a significant public health burden across Eastern Europe and the Balkans. Bulgaria illustrates this paradox: HPV vaccination coverage is very low, and prevention continues to rely substantially on opportunistic screening, although recent national initiatives have introduced HPV-based testing and self-sampling. This article argues that the primary barrier to cervical cancer control in Bulgaria is not the lack of medical technology, but the absence of a structured, organized screening system. A modern national cervical cancer screening program should be recognized as a structured clinical and organizational pathway rather than a single diagnostic test. Such a programme requires population identification, active invitation and recall, reg-istry-based tracking, standardized referral and follow-up pathways, and continuous quality assurance. Primary high-risk HPV (hrHPV) testing provides high sensitivity and excellent negative predictive value, supporting longer screening intervals; however, screening for HPV positivity alone is insufficient as a sole referral criterion because many infections are transient and clinically insignificant. We propose a rational framework for cervical cancer screening in Bulgaria and comparable health systems: invitation-based screening for women aged 25-65 years built on primary hrHPV testing with genotyping, reflex cytology, and selective use of p16/Ki-67 dual staining. Drawing on a regional comparison of HPV vaccination and screening programs and on Bulgarian cost-of-illness data, we argue that transitioning from opportunistic testing to an integrated, registry-based screening cascade is essential for effective and equitable cervical cancer prevention in the region.