1. Cervical Cancer in Sudan
By
Dr. Aida Ahmed Fadlala
Dr. Dina Sami Khalifa
Geneva Foundation for Medical
Education and Research
GFMER Sudan 2012
Forum No: ( 2 )

2. Name of presenter
Name Position Institution
Aida Ahmed Fadlala Obs/Gyn Nursing Head UMST
Department
Name of contributors
Name Position Institution
Dina Sami Khalifa Epidemiologist Ahfad University for
Women (AUW)
Nuha Ahmed Kamal Research Fellow- RCRU UMST
Amjaad Farah Research Fellow- RCRU UMST

3. Content of the presentation
• Background on Ca Cervix
• Ca Cervix in Sudan
• Solutions for Ca Cervix
• National Initiatives
• Gap in Research
• Recommendations

4. Background on Ca Cervix
The cervix is the lower, narrow end of the uterus that leads to
the vagina.

5. Stages of Ca cervix:
• Precancerous changes, known as dysplasia
(months or years)
 aim of screening  Early detection treated by
cryosurgery, cauterization, or laser surgery Highly
curable at that stage.
• Invasive cervical cancer:
1. Stage I: cancer cells only in cervix.
2. Stage II: tumor grown through cervix and invaded
upper part of the vagina but not pelvic wall or
lower part of the vagina.
3. Stage III: tumor invaded pelvic wall or lower part
of vagina.
4. Stage VI: tumor invaded bladder or rectum or
spread to other parts of the body (e.g. lungs)

6. Signs & Symptoms
S&S very common to other female infections and
health problems
• Early cancer is usually symptomless
• Larger tumours causes:
 V. Bleeding:
• Between regular menstrual periods.
• After sexual intercourse or a pelvic exam
• Longer or heavier periods
• Bleeding after menopause
• Increased vaginal discharge
 Pain: Pelvic Pain or pain during intercourse

7. In Sudan: (Data from two National Oncology
Centres/ Khartoum*)
• 8 –10 000 New Cancer Cases are treated in the two
oncology centers.
• Expected cancer cases 39 –40 000 new Cases every year
 Cases seen far less than expected cases
• Ca cervix : 2nd most common cancers in females in
Sudan.
Breast Cancer 29 –34.5%
Cervical Cancer 12 –15.5%
* Radiation and Isotope Center in Khartoum (RICK), and the National Cancer Institute of the University of Gezira
(NCI-UG) in Wad Medani, Gezira State (formerly “Institute of Nuclear Medicine Molecular Biology & Oncology”,
INMO) .

8. • 70 % of women with Ca Cervix present with
Vaginal bleeding and discharge for more than 3
months i.e. present late with symptoms.
• 80 –85 % of cases Present with stages 3 and 4.
• 5 % Present with Renal Failure, 4 % with Fistulas.
• Mostly Postmenopausal Females with more than
3 months history, too shy to complain about
Vaginal bleeding and discharge.

9. Why Advanced cancer in Sudan:
• Lack of a awareness of Cervical smear and vaccination.
• Lack of Effective Health Education and Early Detection.
• Poverty, Illiteracy, the large size of the Country, Local
healers ,the poor distribution of the limited Medical
resources and lack of policies and commitment.
• Lack of Knowledge about Cancer among some
Medicals and Para medicals.
• The limited number of Cancer Hospitals (two) and
Oncologists.

10. Treatment options:
Surgery
Radiation therapy
Chemotherapy
A combination of these methods
The choice of treatment depends on :
• Size of the tumor.
• Metastasis.
• Future preference for pregnancy.

11. Causes and Risk Factors of Ca Cervix
• Early Age at first sexual intercourse
Young women 15-19 currently married/in union
23.4 % ¹
• Multiple sexual partners or a partner who
has had multiple sexual partners
• OCPs
OCP use is Sudan is 6.3 % ¹
• Social economic status
36 % of women fall in the two lowest wealth
quintile¹
¹SHHS 2010

12. • Parity
TFR in Sudan 5.6 ¹ .
Theory: Increase in TFR will decrease Ca cervix (no
evidence of that from poor countries)
• Smoking
Local evidence: Ca Cervix is associated with
smoking among Sudanese women *
• STDs
Prevalence rate 4.7 case/1000 population (1999/
under reported) (Sudan National Strategy for RH)
• HPV
No local evidence on HPV burden
¹ SHHS 2010
* A Idris, H Mustafa, A ismail et al. Impact of tobacco use as a risk factor of cervical cancer among Sudanese
women. 2011. SMJPH, (6);3

13. Estimated Incidence of cervical cancer in Sudan,
Northern Africa and the World (per 100,000
population per year)*
Indicator Sudan North World
Africa
Crude Incident Rate¹ 4.5 5.2 15.8
Age standardized Incident 7.0 6.6 15.3
rate
Annual number of new 923 5278 529828
case
Note: Incidence of cervical cancer in Sudan by cancer registry
NOT available
*WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in
Sudan. Summary Report 2010. [Date accessed]. Available at www. who. int/ hpvcentre
¹ IARC, Globocan 2008. (Specific methodology for Sudan: ’All sites but skin’ incidence rates from Egypt, Aswan (1999-
2002) were partitioned by cancer site, sex and age using proportions obtained from the recorded new cancer cases
in Gezira (2006) and Khartoum (2007) cancer registries. The incidence rates were applied to the 2008 population.

14. “Solutions for Ca cervix”
Prevention :
• HPV testing & vaccination  No national
HPV vaccination protocol in Sudan
Local Evidence :
No local estimate of HPV burden.
One study (2010): The high risk HPV
genotypes (16-58) were not associated with
cancer in Sudan.¹
¹ Salih et al. Genotypes of human papilloma virus in Sudanese women with cervical pathology. Infectious Agents
and Cancer 2010, 5:26. http://www.infectagentscancer.com/content/5/1/26.

15. • Health professionals  key role in cervical
cancer control :
1. Identifying women for whom cervical
screening is recommended (age, SES, sexual
history..etc)
2. Educating women about the importance of
regular Pap tests.
3. Informing women of the need to seek
medical attention for abnormal vaginal
bleeding and other clinical symptoms,
regardless of a normal Pap test result.

16. Screening for Ca cervix:
Goal:
• “Application of a relatively simple, inexpensive test to a
large number of persons in order to classify them as
likely, or unlikely, to have the cancer so as to decrease
incidence , morbidity and mortality from Ca cervix.”
(ref BC)
Success of screening depends on four related factors:
 Women’s participation (High coverage, effective,
acceptable)
 High Sample quality (quality assurance training)
 Laboratory performance.
 Adequate management and treatment of detected
abnormalities

17. Types of screening and confirmatory tests
• Asymptomatic women with clinically clear cervix
 The Papanicolaou (Pap) smear for cervical
dysplasia and early invasive carcinoma of the
cervix.
Local evidence: no available data on coverage or
effectiveness of pap smears.
• Symptomatic women  high false negatives with
Pap smear  biopsy.
“A woman with a visibly abnormal cervix or
abnormal bleeding should be referred
appropriately, regardless of the Pap test
findings”

18. • VIA: “Visual Inspection using Acetic acid”
Local Evidence ¹:
VIA has higher sensitivity and lower specificity
compared to Pap smear.
VIA is useful for screening of cervical cancer in
the primary health care setting in Sudan.
“No cost effectiveness studies on VIA available
to date”
¹ Cervical cancer screening in primary health care setting in Sudan: a comparative study of visual inspection with
acetic acid and Pap smear International Journal of Women’s Health 2012:4 67–73

19. National initiatives :
At Policy level :
• Screening for Ca cervix is one of the prioritized
components in National RH policy strategies.
Targets: (2006-2010)
• Establish a screening program for breast
cancer and cancer of the cervix
• Strategies:
 Pre-service and in-service training of RH
service providers on Ca breast & cervix
screening.

20.  Developing of national protocols and
guidelines on screening for breast cancer and
cancer of the cervix for all levels of the health
care system.
 Providing of needed equipment in the PHC
centers for pap smear and proper referral to
cytology centers.
 Establishing of two specialized centers for
management of cases of breast cancers and
cancer of the cervix, with provision of needed
trained staff, equipment and supplies

21. Sources of funding to implement strategies
40% from public funding & 60% from external
funding
Where are we now ?

22. At Program level :
NCCP in 1982 to:
1. To update the Radiation & Isotope Centre of
Khartoum (RICK) to provide adequate
therapeutic and diagnostic facilities for cancer
patients,
2. To develop sufficient trained healthcare
personnel to meet cancer patients needs,
3. To develop a programe for early detection of
cancer.
• Evaluation data on effectiveness, efficiency,
competence appropriateness and accessibility of
program not yet available

23. At Facility level :
1. lack of facilities to perform the screening
2. Two cancer hospitals in Sudan:
 Radiation and Isotope Center in Khartoum
(RICK)
 National Cancer Institute of the University of
Gezira (NCI-UG) in Wad Medani, Gezira State
(formerly “Institute of Nuclear Medicine
Molecular Biology & Oncology”, INMO)
1. lack of personnel to perform the proper quality
sample collection for screening
2. Lack of qualified oncologists

24. Gap in research:
• Population data on incidence and prevalence
of ca cervix and its risk factors.
• Cost effectiveness studies of the different
screening protocols.
• Health equity studies to highlight social
determinates of Ca cervix in Sudan so as to
target prevention with evidence.

25. Recommendations
1.Avail screening programs in all hospitals with
trained health workers and nurses in this
program.
2.Incorporate Health Education about Cancer
and Early Detection Activities, in the Primary
Health Care System, this is the most effective
strategy.
• Develop Curriculums' for Cancer Control.
• Governments long Term Strategies and Plans
are needed.

26. Thank you