Cancer care in a fragile health system: effects of armed conflict on access, continuity, and mental health in Sudan

Abstract

Armed conflict severely disrupts cancer care, particularly in low- and middle-income countries with fragile health systems. Since April 2023, the war in Sudan has crippled oncology services, yet empirical evidence on its impact on cancer patients remains scarce. Therefore, this study assessed the effects of the conflict on cancer care access, treatment continuity, psychological well-being, and key challenges faced by patients in Sudan. A cross-sectional analytical study was conducted from June to August 2025 at two oncology centers in River Nile State, Sudan. Adult cancer patients diagnosed before April 2023 were recruited by convenience sampling, and data were collected using a validated questionnaire. Descriptive statistics and chi-square or Fisher’s exact tests were performed using SPSS version 27, with statistical significance set at p ≤ 0.05. A total of 384 cancer patients participated, of whom 233 (60.7%) were female and 203 (52.9%) were internally displaced. Difficulty accessing cancer treatment due to the war was reported by 263 patients (68.5%), mainly because of financial constraints 190 (72.2%), medication shortages 175 (66.5%), travel difficulties or insecurity 163 (62.0%), and limited availability of healthcare professionals 129 (49.0%). Treatment interruptions were reported by 161 patients (41.9%). A total of 138 patients (35.9%) had severe psychological impacts. In a multivariable ordinal logistic regression analysis, a higher psychological effect was independently linked to treatment access difficulties (B = 0.961, 95% CI: 0.385–1.536, p = 0.001). In a similar vein, individuals who skipped or postponed treatment sessions were more likely to experience a psychological impact than those who did not (B = 1.035, 95% CI: 0.258–1.811, p = 0.009). Additionally, security threat exposure was an independent predictor (B = 0.610, 95% CI: 0.093–1.128, p = 0.021). The strongest correlation was found between family economic difficulty and both moderate (B = 2.283, 95% CI: 1.425–3.142, p < 0.001) and severe (B = 3.666, 95% CI: 2.768–4.564, p < 0.001) levels. Limited access to health professionals and security-related travel barriers were rated as the most important challenges. The conflict in Sudan has severely disrupted cancer care, limiting access to treatment, interrupting continuity of care, and worsening psychological and economic burdens. Key barriers, including limited oncology services, medication shortages, insecurity, and financial hardship, were associated with poorer psychological outcomes. Urgent implementation of conflict-adapted strategies is needed to ensure safe, flexible care, maintain treatment continuity, and provide essential psychosocial support in resource-limited settings.