The population in Turkey is about 76 million. The population annual growth rate is 11.2 ‰ for 2013. The average life expectancy is 75 years (F 77, M 72). One fourth of the population is 14 years of age and younger [3–9]. The gross national income (GNI) was reported as 10,830 US dollars per capita in 2012. The incidence of cancer is 227 per 100,000 which means about 175,000 new patients each year [10]. Cancer is the second cause of death with a rate of 20 % after cardiovascular diseases (39.9 %) in adults in Turkey [3, 10–12]. The most frequent cancers in adult females are breast (28 %) and thyroid (10.3 %); and in adult males are lung (31.2 %) and prostate (13.7 %) [3, 10–12]. The most significant difference of Turkey from developed countries has been the higher number of cancers caused by tobacco. Turkey had one of the highest smoking rates in the OECD in 2007 [13]. It was reported that cancer incidence had increased annually by 6 % due to the tobacco problem. For men, the cancer incidence rate of 165.8/100,000 for years 1993–1998 had increased to 216.3/100,000 by year 2003. For women, the cancer incidence rate had increased from 97.3 to 152.2/100,000 in the same decade [11, 12]. In Turkey, the incidence of lung cancer is 63 %, and incidence of the cancer of the larynx is 10 %, whereas the same incidences in the European Union are 55 % and 8 %, respectively [11, 12]. Many patients have delays in diagnosis and are diagnosed at advanced stages [3, 4, 10–12].

Turkey became a smoke-free country on July 19, 2009—the use of tobacco in all areas except open air areas was banned by law. This has led to a significant decrease in the use of tobacco in Turkey. The success of the law is reflected in the most recent data which show that exposure to secondhand tobacco smoke has decreased substantially since 2008 [13]. In 2010, Turkey was awarded for this achievement by WHO Director General’s Special Recognition Award [13]. It is expected that cancers induced by tobacco such as lung cancer will decrease in the future. For pediatric cancer, survival rates are around 80 % in the USA. Approximately 250,000 children worldwide develop cancer each year, of whom 200,000 live in MIC and LIC. Every year in Europe 15,000 children aged 0–14 years and 20,000 teenagers and young adults aged 15–24 years are diagnosed with cancer [14]. In Europe, overall survival at 5 years continuously improved from 76.1 % in 1999–2001 to 79.1 % in 2005–2007 [14]. However, 6000 young people in Europe still die of cancer each year despite best available treatments. Across Europe there are still major disparities in 5-year survival, for example, Eastern Europe reports 10–20 % lower survival rates [15]. Cancer remains the commonest disease causing death beyond the age of 1 year in Europe. The types of cancer occurring in this age group in Europe are similar to those observed in the rest of the world [16]. Middle East includes countries from North Africa to central Asia. This region includes a wide spectrum of economically diverse countries, from technically advanced countries with high level cancer care to countries with little or no cancer treatment capabilities. There are large discrepancies in population size, wealth and health expenditure, and availability of quality of treatment. The relative overall cancer survival rate can be around 60 % in some; however, it is only 30 % in most [17].

The International Union Against Cancer (UICC) initiated a world cancer campaign in 2005 to increase awareness, improve care, and coordinate the training professionals using the support offered by the NCI (USA), International Society of Pediatric Oncology (SIOP), and the International Confederation of Childhood Parent Organizations (ICCCPO) and Sanofi–Aventis [18, 19]. This project promotes twinning programs to transfer information, technology, and other supports required to improve cancer care for those children with inadequate access to curative and palliative care. The current president of UICC, T Kutluk, is a Turkish pediatric oncologist.

According to childhood mortality, cancer is the fourth cause of death (7.2 %) in Turkey, after infections, cardiac deaths, and accidents [3, 20]. Each year in Turkey, 2500–3000 new childhood cancer cases are expected [20–22]. According to the Turkish Pediatric Oncology Group (TPOG) and Turkish Pediatric Hematology Society (TPHD) Registry, that was initiated in 2002, about 2000 new pediatric cancer cases are reported each year [20]. The distribution of major cancers in children are leukemia (32 %), lymphoma (17 %), and central nervous system neoplasms (13 %). Five-year survival rate in children with cancer in Turkey is reported as 65 % [20–22]. Higher survival rates are reported in specific cancer centers. Among 2413 patients, mostly solid tumors, diagnosed and treated between 1990 and 2012 in the Istanbul University, Institute of Oncology, Division of Pediatric Hematology–Oncology, the 5-year survival rate is reported as 74 % [22].

Both adult and pediatric oncology national groups are established in Turkey. The Turkish Society of Medical Oncology (TSMO) was established in 1996. Palliative Care Society was established in 2006 and cooperates with European Society of Medical Oncology (ESMO) Palliative Group. The Turkish Radiation Oncology Group (TROG) was established in 1993. TPOG and TPHD were established in 1997 and 1999, respectively. The first group has the main role of management of children with cancer and improvement of pediatric oncology in Turkey via meetings and courses. The second group chiefly focuses on nonmalignant hematology, also leukemias and transplantation [3]. Aforementioned three oncology groups (TSMO, TROG, TPOG) together organize the national cancer meetings with parallel sessions for medical doctors and nurses. In cooperation with the Ministry of Health, TPOG has been organizing regional pediatric oncology postgraduate courses in different regions of Turkey for general practitioners, physicians, and nurses to increase awareness of pediatric cancer throughout the country. To date, education has been provided to 850 professionals in 12 different cities. European Society Medical Oncology (ESMO), European Society for Radiotherapy and Oncology (ESTRO), Middle East Cancer Consortium (MECC), Asian Pacific Organization for Cancer Prevention (APOCP), and SIOP congresses and postgraduate courses have been organized in Turkey. Furthermore, these societies and other non-governmental organizations (NGOs) come together at the National Cancer Week Symposium held by Ministry of Health, annually. Turkey is a member of the MECC that aims to promote cancer registry, epidemiology, and mortality and also supports palliative cancer care and encourages cancer education and research through meetings held in various Middle East countries, including Turkey [3].

The Ministry of Health cooperates with numerous national and international institutions and agencies in the fight against cancer. The Ministry has put the National Cancer Control Program in cooperation with the following international organizations: WHO, International Agency for Research on Cancer (IARC), International Association for Cancer Registry (IACR), UICC, National Cancer Institute (NCI), APOCP, MECC, National Health Service (NHS) [3–5, 20]. The program includes five main headings: Registry, Prevention, Screening and Early Diagnosis, Treatment and Palliative Care.

According to our regulations, after completing 6 years of education in the medical faculty, the title of “medical doctor” (MD) is obtained [3]. An MD has to complete a 4-year training resident program in internal medicine or pediatrics to be a “specialist in internal medicine or pediatrics.” Afterwards, a further 3-year fellowship program in medical oncology/pediatric hematology–oncology has to be completed to become a specialist in medical oncology (medical oncologist) or pediatric hematology and oncology (pediatric hemato-oncologist) [3]. The specialty and subspecialty training is given in university hospitals or government tertiary training and research hospitals authorized to provide training by the High Education Council and the Ministry of Health. The specialty and subspecialty certificates are awarded by the Ministry of Health. The nurses in Turkey are either graduated from high school for nursing or from universities for nursing. Clinical nursing education is carried out by faculty members of nursing schools after completion of or in conjunction with theoretical courses. Since April 2007, men have been accepted into nursing programs in Turkey [23].

In general, there are no certified PC/hospice care specialist nurses. PC in general has not been incorporated yet into the curriculum of nursing at both undergraduate and postgraduate level. There are prominent psychologists and psychiatrists only in a few oncology centers, in most others a psychology/psychiatry consultation is requested from the related department as needed. There are scarce social workers and almost no art therapists employed in most oncology centers. There are no specifically trained spiritual counselors both for adults and children. The doctors and nurses try to cover the role of the psychologist, social care worker in many centers. Recently, Ministry and Ankara University collaborative training program has been started for spiritual counselors [3].

Turkey is a country where the cultural aspects of the society are blended both by the Eastern and Western societies. A myth about cancer treatment is common among Turkish community. Patients having mass in their viscera are often reluctant to undergo surgery because they believe “if there is a cut through a cancerous mass, it will spread all over the body” [24]. This misbelief has changed in recent years with the success of advances in medicine and increased awareness of the society. Screening for some types of cancer has led to early diagnosis, thus increased survival, although it yet needs much improvement. Gynecological or breast cancers may present with symptoms that women are reluctant or shy to visit a doctor, and they might be less willing to undergo necessary examinations to investigate the cause of such symptoms, and this may cause delay in diagnosis [25, 26].

In Turkey, most patients diagnosed with cancer receive the standard oncological treatment which is completely funded by the government. In addition, most use some herbal medicines as well. The study of traditional uses of plants in the world in general and in the Mediterranean region in particular has been progressively increasing during the past few decades [27, 28]. According to WHO, the international market of herbal products is estimated to be US$ 62 billion which is poised to grow to US$ 5 trillion by the year 2050 [29]. Turkey is one of the richest countries in terms of plant diversity. Approximately 10,500 plant species have been identified and 30 % of this is endemic [30]. There are around 347 medicinal plants used in Turkey, 139 of which are exported [31]. A study performed at a university hospital in the Mediterranean region of Turkey, established that 50 % of the patients used mainly medicinal herbs, and the most frequently used (87 %) plant was stinging nettle (Urtica dioica) [32]. However, the majority used more than one item. The study also showed that the other remedies were honey, pollens, “pekmez” (a traditional syrup obtained mainly from boiled grape juice or other fruits), garlic, olive oil, rosehips, parsley, spice mixtures, avocado, bango tea, chestnut honey, carrots, hemp, mushroom tea, oregano, turnip seed, black grape seed, red berries, extracts of Salvia officinalis, Semen nigellae, and oleander [32]. Interestingly, the most popular complementary methods, such as prayer, meditation, massage, relaxation, and special diets reported from western countries, were not the remedies of Turkish people. Other plants used frequently in various parts of Turkey may be listed as:

Sonchus asper, Urtica dioica, Viscum album, Asphodelus aestivus, Cynarascolymus, Ficus caricar, Hypericum perforatum, Lagenaria siceraria, Matricaria chamomilla, Neriumoleander, Picnomon acarna, Pinus brutia, Plantago major, Portulacaoleracea, Rosa canina, Urtica pilulifera, Calendula arvensis, Cichoriumintybus, Dracunculus vulgaris, Pistacia terebinthus, Anthemis tinctoria, Zea mays, Anthemis tinctoria, Heracleumtrachyloma, Astragalus brachycalyx, Thymus kotschyanus [33–37].

In many Middle East countries, many individuals believe in their own spirituality and faith when coping with illness. In addition to standard cancer treatment, this might contribute positively to the outcome of the cancer. Positive way of thinking might influence serotonin pathways in the brain that regulate mood and possibly pain [24, 38]. In a survey, it was stated that many patients believed that “everything comes from God and one should never give up hope of God’s mercy.” This belief could be a reason for high levels of hope [39, 40]. Advances in technology, cancer treatment and supportive care, adequate family support, and the presence of governmental health insurance were reported as other factors for high levels of hope. Financial problems were reported to negatively affect the psychological distress and thus adversely affect the level of hope in this study [39]. The future subscale and total hope scores of patients were found to increase with their information level about the disease. Similarly, in the study of Durusoy et al. [41], more than half of the patients (63 %) stated that they would like to know all the details about their disease.

In the USA and other developed countries, most children <15 years are treated in clinical trials and the high survival rates achieved is suggested to be due to building up protocols according to statistically significant data resulting from trials. In adults, the number of cancer patients treated in clinical trials is less than in pediatrics, even in developed countries, but most are treated according to guidelines or accepted protocols.

Adolescents are sometimes treated by pediatric oncologists, sometimes by medical oncologists in most countries. They usually are not put into trials due to physicians’ or patients’ choice. In some developed countries, adolescents and young adult (AYA) clinics have been developed that address the physical and psychological needs of this age group. Recently, in the USA, many COG studies recruit adolescent and young adults in pediatric treatment trials, since there are reports that the survival rates in some cancer types have increased when pediatric protocols were used. According to recent regulations in Turkey, all cancer patients up to 18 years of age are treated by pediatric oncologists.

Most centers in Turkey treat their patients according to worldwide accepted US- or European-oriented protocols. Medical oncologists in some oncology centers in Turkey, mainly in universities in big cities, participate in phase II and mostly phase III international clinical trials that are designed mostly by the USA or European centers [42, 43]. In Turkey, children with cancer are treated either by national protocols/trials developed by TPOG or by international clinical trials/protocols developed mostly in the USA or Europe such as protocols by SIOP and Children’s Oncology Group (COG). Some of the pediatric oncologists have also participated in phase III international trials such as the SIOPEL liver tumor randomized treatment trials or brain tumor trials [44, 45]. Also, pediatric oncologists in Turkey, as the first author of this chapter (RK), has participated in some international guidelines such as febrile neutropenia for pediatric cancer [46] and some treatment strategies for developing countries [47]. Among TPOG protocol studies, Wilms tumor [48] and neuroblastoma studies [49] can be mentioned. A nationwide pediatric cancer registry is also active under TPOG governance since 2002 and is currently conducted by both TPOG and TPHD [6, 20].

Personalized medicine is the tailoring of therapies to the patients based on the stage of the disease, the response to therapy or risk of adverse events. The goal in cancer treatment should be to use the most effective and the least toxic therapy. Currently, risk-adapted treatment approaches are used both in adult and pediatric cancer. Risk-based treatment leads to decreased toxicity and late effects by decreasing treatment intensity in low risk patients. Chemotherapy intensity may be alleviated or diminished according to the treatment responses. The number of chemotherapy courses has decreased to 2–4 courses in early stage Hodgkin’s disease. Radiotherapy (cranial prophylactic radiotherapy) has been successfully omitted from most acute lymphoblastic leukemia protocols in children except in high risk patients and some special conditions.

Targeted treatment has also proved to be successful in some cancers. In patients having t(9;22) acute lymphoblastic or chronic myeloid leukemia, targeted therapies like imatinib has led to revolutionary results. Furthermore, monoclonal antibodies such as brentixumab, in relapsed/refractory non-Hodgkin’s lymphomas or Hodgkin’s disease, have led to successful responses.

In Turkey, standard cancer treatment and care has been funded by the government for all citizens. Targeted therapies are also funded by the government [50]. In an international survey, patients in Turkey, were the least likely to pay for medical expenses out of pocket, compared with the US or other emerging markets (<1 %) [51].

In Turkey, although oncologists advise and apply standard treatment protocols, they also respect patients’ and their families’ wishes. Mostly, it is the families rather than the patients who participate in the decision. In pediatric cancer, the families are informed of the malignancy and the prognosis of the disease in detail, the child is informed of the malignancy in words that they may understand according to their age. Most parents do not want the doctor to tell the child that they have “cancer,” and the doctor tries to convince the parents to at least use the term “tumor” in the first session. In adults, especially in the elderly, most families do not want the patient to know that he/she has cancer. Changing the orientation towards a more patient-centered approach as is in the USA and Europe needs time [50].

Cancer is the second most common cause of death after cardiovascular diseases in Turkey; therefore, it is an important public health issue. There are cancer centers within the universities and public teaching and education hospitals [3]. There are also three oncology Institutes in Turkey; one in Istanbul (Istanbul University Oncology Institute), one in Ankara (Hacettepe Oncology Institute) and one in Izmir (Dokuz Eylul University Oncology Institute). In Turkey, all medication and hospital services for patients with cancer are provided by the government in university or government training hospitals free of charge [2]. Almost all standard and new chemotherapeutics, including many targeted agents, are available in the market [50]. Taking into account the large number of patients, especially in big cities where the majority of patients are located, hospital beds are always full, the number of patients per doctor is high and the number of nurses experienced in oncology is low [2, 3]. In general, the number of beds in long-term care hospitals (not only for cancer) has increased from 6841 in 2000 to 8469 in 2010 [2, 52]. The number of physicians per 100,000 people (167 in 2010) has grown moderately, but is still lower than that of Greece, Italy, Spain, and Portugal, as well as of the average for the European Union (EU) [5, 52]. Similarly, the number of nurses per 100,000 people (156 in 2010) is the lowest among the countries mentioned. Palliative experts are indeed scarce [2, 3]. Recently, private university hospitals have also taken part in care of this population. The Ministry of Health has planned to build big city hospitals including cancer centers in big cities. There is a serious lack of psychological (psychologist and psychiatrist) support services specific for cancer patients; no social worker, no art therapist in most centers [3]. Due to high number of patients, limited time is dedicated to cancer research. The current health system in Turkey has been designed primarily for the daily care of the patients both at inpatient and outpatient clinics. Despite the heavy clinical burden, academic staff in the university try to do research. Mostly, scientists other than clinical physicians are able to do full time research. Research conducted according to priorities in the society such as the genetic differences in cancer in a particular setting or environmental effect may have relevant results. For this issue, specific tumor tissue banking was planned. A pilot study was performed at Dokuz Eylül University Breast Tumor DNA Bank (DEUBTB) to facilitate sharing of tumor DNA/RNA [53]. At interim phase, the authors suggested that biobanks need to be controlled by the government or regulatory authorities for the necessary funding and quality standards of ethical, legal, and social regulations.