About 72% of the cervical cancer cases in this Sudanese study were diagnosed at an advanced stage. Older age, lack of insurance, African ethnicity, and rural residence were independent risk factors for the diagnosis of advanced cervical cancer. The risk was especially high in women with no health insurance. This finding is consistent with earlier reports.13
Women without health insurance were less likely than those with health insurance to seek health care and to receive appropriate treatment. In this study, nearly 46% of advanced (FIGO stages III and IV) cervical cancer cases were aged over 55 years. Older women were less often diagnosed at an early stage of cervical cancer than younger women. This may be due to older women not seeking obstetrics and gynecology services in the post-menopausal years, and particularly women in rural areas where health care services are not readily accessible. Another likely factor is lack of awareness about cervical cancer.14
Furthermore, a crucial contributor to delayed detection of cervical cancer is probably poor dissemination of information and communication by health care providers.22
In this study, women of African ethnicity were more likely to be diagnosed with advanced disease than those of Arabic ethnicity. Ethnic differences in staging at diagnosis of cervical cancer have been reported by several other studies. Brewer et al26
found major ethnic differences in survival rates for Maori and Pacific Island women with cervical cancer in New Zealand. They reported that this difference was almost entirely due to staging at diagnosis, indicating that ethnic differences in access to and uptake of screening and treatment of premalignant lesions may have played a role. Brookfield et al27
reported similar findings for a population in Florida that included Caucasian, African-American, and Hispanic women. Their study concluded that racial, ethnic, and socioeconomic disparities in cervical cancer survival rates were explained by late-stage presentation and undertreatment.27
In line with our results, Wu et al28
found that certain ethnic groups, ie, Black and Hispanic, as well as older women, were more likely to be diagnosed with late-stage cervical cancer. This difference is due to lack of awareness, poverty, and lack of health insurance, resulting in an underprivileged situation in terms of access to health care services. In our study, there was a difference in geographical distribution between women of African and Arabic ethnicity, but the spatial distribution of African and Arab ethnicity in Sudan (with respect to hospital care) is equal. Spatial disparity in access to health services exists between urban and rural areas in Sudan but there is no clear evidence that populations of African ethnicity concentrate in rural areas. There is a lack of access to health services and health insurance cover in rural areas and this probably contributes to late presentation, again resulting in diagnosis of cervical cancer at an advanced stage.
Single women in Sudan are not usually sexually active and rarely seek reproductive health care, so are unlikely to have regular gynecological examinations. Due to an inherent social stigma about loss of virginity, unmarried women are considered to be virgins. Unmarried women may avoid undergoing a gynecological examination for fear of being stigmatized if it is discovered that they are sexually active.29
Moreover, social mores in Sudan consider sex outside marriage to be sinful, and are widely suspected to affect health care being sought for gynecological symptoms, which are often associated with sexually transmitted infections. 30
In this study, married women were more likely to be diagnosed at early stages of cervical cancer compared with unmarried women, which may be due to the more frequent obstetric and gynecological care they receive during their childbearing years.
There are some limitations to this study. First, data on earlier staging of cervical cancer, such as carcinoma in situ, are not held by the cancer registry, and the tumor stages were classified into broad major stages without substaging. Second, invasive cervical cancer cases were reported to the cancer registry directly from secondary and tertiary care institutions, so data on patients who were not hospitalized would not have been entered into this hospital-based registry. The extent to which unregistered cases may have differed in age, ethnicity, and geographical distribution is unknown.