Worldwide, cervical cancer is the fourth most common cancer in women; approximately 604,000 new cases were diagnosed in 2020, and 342,000 women died from the disease (1). Ecuador has an incidence rate of 16 cases per 100,000 women, placing it in an intermediate position compared to other countries (2). The mortality risk from this cause is 8.2 cases per 100,000 women (2).

Ecuador is a country with a population of more than 18 million inhabitants, mostly female (100.6 women for every 100 men), where life expectancy at birth is 77.6 years (3). It has a Ten-Year Health Plan (2022–2031) whose main objective is to reduce inequalities and inequities in effective, universal and free access to the right to health, through an intersectoral and comprehensive approach to the social and environmental determinants of health (3, 4).

In developing countries, similar to Ecuador, a significant number of patients with cervical cancer are diagnosed in advanced stages of the disease, likely influenced by social determinants of health, both at the individual and collective levels. This limits treatment options to symptomatic and palliative approaches (5).

The World Health Organization (WHO) has launched a Global Initiative to expand preventive, screening, and treatment interventions to eradicate cervical cancer as a public health problem in the twenty-first century. However, the lack of public awareness about this disease is related to the lack of access to health programs promoted by national and international organizations aimed at its detection and prevention. Therefore, it has been considered a disease associated with sociodemographic contexts of poverty (6).

In Ecuador, with the support of the Pan American Health Organization, an HPV vaccination campaign was carried out in 2024 to cover approximately 595,000 girls and boys, in coordination with the Ministry of Public Health and the Ministry of Education, to achieve 90% vaccination coverage in girls (9–14 years old) and boys (9 years old) against HPV (7). This was the first time that boys were included in the immunization campaign, marking an important milestone in preventive health. In Ecuador, the HPV vaccine was included in the national vaccination schedule since 2014 for girls between 9 and 11 years old (8). In 2017, the National Strategy for Cancer Control was launched in Ecuador by the MSP, which includes among the prioritized neoplasia screening activities, screening in women aged 21–65 with Pap smears every 3 years, in women aged 30 to 65 and if possible, screening with cytology and molecular tests for HPV DNA every 5 years (9).

Regarding secondary prevention through screening tests, the MSP has established several campaigns, such as those carried out in March 2023 with the free provision of Pap smears at the Luz Elena Arismendi Pediatric Gynecology and Obstetrics Hospital of Nueva Aurora and genotyping at the Enrique Garcés General Hospital (10, 11).

Approximately 60% of cervical cancer cases are diagnosed at advanced stages, contributing significantly to the high morbidity and mortality rates in women from resource-limited settings (12). In Quito, the Ecuadorian capital, between 2015 and 2019, more than half (52%) of cervical cancer cases were diagnosed at stages III (26%) and IV (26%) (13). In Latin America, various barriers, such as a lack of education, lead to feelings of shame when it comes to detecting this type of cancer. Furthermore, in this context, there are difficulties in accessing vaccination and carrying out regular screening tests (14).

The focus is exclusively on improving detection and treatment, which has led to data from local and national registries and medical records containing very little information on sociodemographic data. This highlights the need for targeted interventions that address socioeconomic disparities to improve access to cervical cancer screening and treatment, thereby reducing the disease burden in vulnerable populations (6, 15, 16). The present study aims to provide an overview of the relationship between survival and sociodemographic variables in women with cervical cancer receiving palliative care at the SOLCA Cancer Hospital in Quito during the study period.

The SOLCA-Quito Oncology Hospital is a specialized hospital serving as a local and regional referral center for cancer care. Located in Quito, the Ecuadorian capital, it has more than seven decades of experience in the management of oncological pathologies, treating patients referred from both the public and private healthcare systems (17).

A total of 368 patients participated, with a median age of 52.5 years (IQR 45–65) (Figure 1). 69.84% of the patients had completed primary education, and 80.71% identified themselves as Catholic. The predominant ethnicities were mestizo and indigenous, with an equal percentage of 46.47%. Most participants had incomes below the basic salary (80.43%), and 44.29% lived with their partners and children, and 68.48% had three or more children. Most patients were referred by the Ministry of Public Health (86.96%) (Table 1).

The analysis of the association of socioeconomic variables with survival in patients with cervical cancer in Quito, Ecuador, is presented in Table 1. Although most of the variables evaluated did not show statistically significant associations, some important differences were observed. Income level was associated with survival (p < 0.05). Likewise, age group and marital status showed significant associations with survival (p < 0.001). Marital status at the time of transition to palliative care also showed a significant difference (p < 0.05), with a change in the proportion of married patients (38.86%). Occupation at diagnosis was also significantly associated with survival (p < 0.05), with similar groups in terms of those employed and those not employed (Table 2).

Although racial and ethnic disparities in cervical cancer incidence and mortality have been widely documented globally, our study suggests that, in this Ecuadorian palliative care cohort, socioeconomic and demographic factors, such as educational level, income, and parity, may play a more prominent role in shaping survival outcomes than ethnicity itself. These findings highlight the importance of addressing social determinants of health when designing care and support strategies for women with advanced cervical cancer.

According to the results obtained, although factors such as ethnicity, marital status, and province of residence do not significantly influence mortality in patients with cervical cancer in palliative care, educational levels appear to be an important risk indicator. Contrary to the well-established protective effect of higher education on health outcomes globally, our study found that women with tertiary or higher education had a significantly higher risk of mortality (aHR: 3.16; 95% CI: 1.51–6.60). This counterintuitive finding may be explained by several context-specific factors. First, patients with higher education in our cohort were more frequently diagnosed at advanced stages (III–IV), possibly due to delayed help-seeking behavior. In Ecuador, women with higher socioeconomic status, often correlated with education, may initially consult private providers where diagnostic pathways for cancer are fragmented or lack integration with public screening programs, leading to delays in definitive diagnosis and referral to specialized oncology centers. In contrast, women from lower-income backgrounds are typically channeled directly through the MSP system, where cervical cancer screening and referral protocols are more standardized, albeit resource-constrained.

Second, our data suggest that tertiary-educated patients had a higher burden of comorbidities. While higher education generally improves health literacy, it may also increase awareness of prognosis in advanced disease, potentially influencing decisions to forgo aggressive treatments or transition earlier to palliative care, though this requires further qualitative exploration.

Importantly, the small number of highly educated women in our sample limits generalizability and may reflect selection bias, as this group is underrepresented in public hospitals in Ecuador. Nevertheless, this finding underscores that the relationship between education and cancer outcomes is not uniform across health systems and may be modified by access pathways, cultural norms, and care fragmentation, particularly in mixed public-private systems like Ecuador's.

Furthermore, having children is associated with a lower risk of mortality, which could reflect a protective psychosocial factor that improves patients' quality of life. Income also influences mortality risk, with those with average income experiencing better outcomes compared to low-income patients.

One of the main findings is that we did not find a significant difference between mestizos and indigenous people in terms of survival in patients from the diagnosis of cervical cancer to the transfer to palliative care and from palliative care to death (23), it may be related to other barriers in vulnerable populations such as lack of knowledge, stigmatization, cultural beliefs and values, religion and lack of resources as limitations to undergo cervical cancer screening prevention (24–27). In the United States, cervical squamous cell carcinoma incidence is higher among African–American and Hispanic women than among non-Hispanic white women (28).

In our cohort, a pattern of reduced partner involvement or support was observed around the time of transition to palliative care, a phenomenon consistent with findings from Fugmann et al.'s systematic review, which reported an increased risk of relationship dissolution among women with cervical cancer. This could be attributed to various factors associated with advanced stages of the disease, such as changes in sexuality, including vaginal shortening and narrowing, dyspareunia, and sexual concerns. Furthermore, patients face increased demands for end-of-life care (29, 30). These changes in sexual life also represent a significant challenge for these patients' male partners (29–32).

The time to initiate palliative care in patients with cervical cancer was approximately 2 years, suggesting that these patients were in advanced stages of the disease. This finding is consistent with data reported from the SOLCA Quito National Tumor Registry, which indicates late diagnosis, with approximately 52% of cases in stages III and IV cervical cancer, implying that these patients require highly specialized treatments. Furthermore, disparities in access to medical care and screening may contribute to differences in cancer stage at diagnosis (33).

The average age of most patients was 50 years; however, 19% of the study population was 71 years or older, which is consistent with studies showing changes in the age at which cervical cancer is diagnosed over the years. According to population data from Ecuador, the proportion of women aged 70 years or older is 6.3% (544,197 women) (34). Considering that the recommended age to stop screening for this cancer varies between 50 and 70 years worldwide, it is necessary to reflect on the possibility of modifying these indications (35, 36). Cervical screening in women around 50 years of age is essential to reduce mortality from cervical cancer in later life. Furthermore, participation in screening programs can significantly influence the reduction of mortality risk (37).

Socioeconomic disparities influence both the incidence and mortality of cervical cancer. In our study, most patients had limited financial means, evidenced by incomes equivalent to a basic food basket. A systematic review found that women from lower socioeconomic levels have worse survival rates, which is consistent with our findings (38). Our study also revealed that most patients were referred by the Ministry of Public Health (MSP), with no private care patients registered, which could be related to the high costs of specialized treatments for advanced cancer.

On the other hand, patients who had more children had higher survival rates, and we believe this is because they were able to provide care to the mother during her final stages and offer her emotional support, which could positively influence the improvement in survival (39, 40). Furthermore, the quality of women's relationships has been shown to be important for their health.

Most patients died at home, which correlates with several studies indicating that cancer patients' preference to die at home is influenced by factors such as family support, quality of home care, and the match between patient and family preferences (41–44). However, few centers in Ecuador provide this care, making the implementation of home-based palliative care, provided by a specialized team, necessary. This is essential to improve patients' quality of life, maximize the use of health resources, and support caregivers, all while respecting the patient's preference to receive care in their home environment (45–47).

In Ecuador, human papillomavirus (HPV) vaccination began in 2014, and HPV genotyping and vaccination for men have recently been implemented in May 2024 (48). The government and non-governmental organizations have worked together to raise awareness about cervical cancer and its early detection. However, strategic decisions will not completely eliminate the barriers to early detection and the low rate of cervical cancer diagnosis in vulnerable populations. It is equally crucial to understand the knowledge gaps, as well as the attitudes, beliefs, educational, and cultural obstacles faced by these groups.

In Ecuador, access to palliative care has been improving in recent years, with the creation of the National Palliative Care Policy in 2022 and the approval of the Organic Law on Palliative Care in October 2024 (49, 50).

Our findings underscore the critical role of socioeconomic determinants, particularly income level, educational attainment, and family support, in shaping survival outcomes among women with cervical cancer receiving palliative care in Ecuador. These insights carry direct implications for the National Cervical Cancer Control Program and the recently established National Palliative Care Policy. First, the observed association between low income and poorer survival highlights the urgent need to strengthen financial protection mechanisms and ensure equitable access to timely diagnosis and treatment, especially for women from vulnerable socioeconomic backgrounds. Second, the protective effect of having children suggests that family-centered care models should be integrated into palliative services, leveraging informal caregiving networks while providing them with formal training and psychosocial support. Third, given that most patients were diagnosed at advanced stages and referred late to palliative care, the program should prioritize strategies to reduce diagnostic delays, such as community-based screening outreach, culturally sensitive health education, and the integration of palliative care earlier in the disease trajectory. Finally, the high proportion of patients dying at home, coupled with the limited availability of home-based palliative services, calls for the rapid scaling up of community palliative care teams, as envisioned in the Organic Law on Palliative Care (2024). Implementing these evidence-informed actions could significantly improve equity, quality of life, and survival for women with cervical cancer in Ecuador.

Our study has several limitations that should be considered when interpreting the findings. First, the retrospective design and single-center setting, restricted to a public hospital in Pichincha province, introduce selection bias and limit the external validity of our results. The sample predominantly included women referred by the MSP, with no representation from private healthcare sectors, which may skew the cohort toward lower-income populations and underrepresent women with different socioeconomic profiles or access pathways. More importantly, this geographic and institutional constraint restricts our ability to capture the full heterogeneity of social determinants of cervical cancer across Ecuador's diverse regions, including Indigenous communities in the Amazon, Afro-Ecuadorian populations on the coast, and rural highland groups, each of which faces distinct structural, cultural, and systemic barriers to prevention, diagnosis, and palliative care. Consequently, while our findings offer valuable insights into the role of income, education, and family support in one urban context, they may not fully reflect the complex interplay of social determinants operating in other sociocultural or geographic settings within the country.