The prevention and reduction of cancer cases require cancer control programs to be implemented. A cancer registry system is considered a major component of cancer control programs. Iran’s Cancer Registry was approved in 1984 and published its first cancer registry report in 1986 with 18,435 cases of cancer. The second cancer registry report of 1996 was published in 1999 with 11,025 cases of cancer. This report had registered only 18 % of all the new cases of cancer. Until 2007, cancer registration was based only on pathology reports. However, due to the system’s failure to diagnose cancers that are diagnosed without biopsy, such as brain cancer, a population-based registration system was established across 20 universities of the country in 2008 to complement the pathology-based registration. The statistics rose to 74,067 cases of cancer in 2009. Tehran has qualities that make it perfect for being the center of cancer registry, for example, being home to 10 % of the country’s population, to diverse ethnic groups and also to various centers [13].

The National Cancer Registry of Iran covers the whole area and the entire population of the country. Cancer registry is administered centrally by the Ministry of Health and Medical Education. Collected cancer data are sent to the Cancer Office by the health deputies to be published in the form of national reports after thorough statistical analysis. Although the first comprehensive registry report was published in 2004, no such reports have yet been published in the book “Cancer incidence in five continents.” The registry is entirely funded through state budgets by the Ministry of Health. There are no independent registries or registrars at the provincial level; instead, data is collected by health deputies [14]. This 5-year program is intended to achieve the desired results in pilot provinces over the next 5 years, and then, if required and if the necessary infrastructures are in place, to be extended to the entire country [15].

Pain caused by cancer itself or the complications arising from its treatment procedures affect 50–90 % of the patients with cancer. Uncontrolled cancer pain sometimes pushes patients toward suicide [16]. Pain and its management comprise a crucial aspect of cancer care. Pain is a global phenomenon that affects quality of life in people across all cultures. Culture affects all the aspects of the experience of cancer in the patients, their family caregivers, and professional healthcare providers, including the perception, expression, and treatment of pain by the patient and their family. Cultural background has long been recognized as an influential factor in understanding the perception of and the reaction to pain. Findings of studies have shown that family culture, beliefs, and religion play a decisive role in the perception and management of pain by patients and their caregivers. All members of the multidisciplinary oncology team who provide care for the patient should be attentive to the patient’s cultural beliefs associated with his health and take advantage of them in their care [17].

There are different cultural and belief perspectives about pain. In some cultures where religion plays a strong role, pain is believed to have been granted by God, and it is a human obligation to tolerate pain; in these cultures, pain is an accepted and anticipated form of life; in other words, pain and disease are human fate and should be tolerated, or else result from the evil deeds of humans [17]. In Islam, pain and suffering is regarded as the patient’s atonement for sins [18]. That is why most people consider cancer similar to the tolerating of pain and suffering [19].

In a study conducted with the purpose of determining the relationship between attitude to pain relief and receiving analgesics in patients with cancer, most patients were of the attitude that analgesics are addictive, which might owe to their poor information. Yet, at the end stages of disease, the patient’s pain relief and comfort take priority. According to results, patients with the attitude that analgesics are addictive used significantly less amount of opioids than others. Patients with fewer false beliefs and attitudes about pain and the management of pain received sufficient analgesics and were thus able to effectively and adequately control their pain [20].

According to statistics provided by the International Narcotics Control Board (INCB) on the use of opioid analgesics, Iran ranked 115 in the world, 25 in Asia, and 15 in the region, therefore grouped among the low-consumption countries. Nevertheless, Iran is a rich country in terms of raw materials and manufacturing technology required for the production of opioid analgesics, and Mehrdarou, Exir, Shadarou, Daroupakhsh, and Tofighdaru companies produce drugs such as methadone, codeine, oral oxycodone, and morphine injection. The drug formulary used in Iran for opioid analgesics, in particular non-synthetic analgesics, complies in part with the World Health Organization’s approved list. These drugs are also so inexpensive that require almost no economic support system at all [21]. A report published in February 2013 assessing the method of opioid use in palliative care attributes the low consumption of these drugs to the lack of proper access to opioid drugs and also, in some cases, the negative attitudes of physicians, patients, and their families to opioid drugs [21].

In a study conducted by Mohagheghi et al. (2003) on 304 cancer patients, the patients’ most frequently used opioid drug included morphine injection, oral opium, and methadone (injectable and oral). These researchers also noted the inadequate variety of opioid drugs in Iran and the unfamiliarity of most physicians and almost all patients with the inadequate medical and administrative route for the prescription and preparation of the opioids. The available prescription drugs are also not used in a systematic fashion, and inappropriate use, including abuse, low or high dosage, improper administration route and sequence and carelessness about drug interferences, is widely witnessed. Standard instructions issued by university committees in partnership with the Ministry of Health might be helpful in resolving the current problems [22]. Stringent rules govern the use of opioids in Iran, and due to the absence of statistics on the level of opioid use in cancer patients, this data can only be accessed through a patient registration system in universities of medical sciences across different regions of the country. In Iran, the Food and Drug Department stationed in every university of medical sciences is responsible for providing the opioid drug demands of the medical centers within its area of coverage. The office of Controlled Drugs and Substances of each deputy is responsible for filing separate records for all patients demanding these drugs. Patients who have been using opioids for over a year should be examined by a medical committee, and should be able to refill their prescriptions after their disease and their opioid demands are confirmed once more. After this step, patients can refill their prescriptions for one more month [21].

All the health systems across the world are faced with the rising costs of health care threatening high quality care. Health care costs have also sharply risen during the past few years in Iran , posing challenges to the state, insurance companies, and patients. In Iran, there are three sources for budgeting health care, including public state funding, health insurance payments, and individuals’ out-of-pocket expenses [23]. Although the country’s health budget has been constantly increasing in recent years, and thought it has now three times its previous amount, out-of-pocket expenditure on health remains as high as 55 % [24].

The treatment of cancer is a vital medical obligation. Treatments performed on cancer patients are often invasive and severe and require large expenditure of resources. Treating cancer is a costly affair that not only threatens life and welfare, but also puts the patient’s financial security at risk [25]. In Iran, patients with cancer have to travel long distances to receive proper treatment, which increases the financial burden imposed on them or their families. The demand for the treatment of cancer and its associated financial pressures can be a strong source of stress for the patients and their families, particularly in the case of low-income patients. The early estimation of the costs of care for cancer patients is an important component of the development of national cancer policies and programs. Cancer costs of patients are at their peak during the first 6 months after diagnosis and the last 12 months before death, and they significantly reduce between these two stages [25].

A major challenge posed to the treatment of patients with cancer is the discriminate distribution of specialists across the country, which somehow increases costs incurred by patients. For instance, it appears that the dense concentration of more experienced specialists and stronger diagnostic services in Tehran, the country’s capital city, allows the patients to be diagnosed with fewer doctor’s visits and diagnostic services. The high costs of treatments such as chemotherapy and surgeries incurred by patients in Tehran are attributed to the stronger, more active presence of the private sector in Tehran, while in other cities, patients usually use the cheaper services of the public sector [25].

Adopting new policies to cover the costs incurred by cancer patients, particularly by insurance companies, receiving funding through institutions such as banks or charities, the indiscriminate distribution of specialized cancer centers or providing temporary accommodation to patients traveling from other cities can reduce the financial burdens imposed on cancer patients and help them in their management of the disease, in addition to also realizing health equity indicators [25].

Many studies have been conducted on the inadequacy of palliative care training in various medical groups, mostly targeting nurses and physicians. Some of these studies have suggested that nurses are still inadequately skilled and not very efficient in providing palliative care and that they require better training for this particular concept and type of care [26].

The main problem of the nursing system in Iran in relation to palliative care for cancer patients is that no clear framework exists for this type of care for nurses and that it does not have a strict presence in the official curriculum. One reason for this problem appears to be the lack of comprehensive studies on this subject in the country, which limits the applicability of the concept of palliative care to these patients [27]. Findings of a study conducted for “examining the attitude and motivation of nursing students for finding work in cancer departments” showed that nursing students did not have a positive attitude toward working in cancer departments, and showed their mean overall score for attitude toward working in cancer departments and all of its components to be low. The incompatibility of the content of theoretical courses on cancer and the real needs in cancer departments ranked lowest among all motivational factors. The lack of adequate communication and care skills for patients at end-of-life stages and the incompatibility of the content of theoretical courses on cancer and real-life needs had contributed greatly to the students’ negative attitudes [28].

In many countries, General Practitioners (GPs) are the main responsible authorities for providing patients with medical care, in particular palliative care. In Iran, given the extension of the role of GPs to family doctors, it appears that they will also play the main role in this area. However, there is no formal palliative care training in Iran during the course of general practice education [6]. Results of a study show that, in Iran, only 12 % of GPs have excellent or very good knowledge of palliative care and more than half of them have poor or no knowledge in this area. Only 22 % of participating physicians knew about the WHO pain control guidelines and were well acquainted with the management of patients’ physical symptoms. More than half admitted their poor knowledge of pain control, the principles of end-of-life care and palliative care. It appears that the deficient knowledge of physicians on palliative care is rooted in the medical education system in place in Iran, which is mostly symptom based rather than holistic [6].

Despite the guidelines provided by the World Health Organization on the management and treatment of pain in cancer patients, pain is still not well managed in these patients. A main barrier to the control of pain in these patients is the physicians’ deficient knowledge. In a study conducted on this subject, the main barrier to the proper management of pain was the absence of pain control specialists and the personnel’s lack of knowledge on pain management. The majority of physicians who participated in this study asserted that they were unhappy about the pain management training they had received during their medical education [29, 30].

Given the importance of a well-established, specialized workforce for providing this type of care, and in response to the shortage of human resources at both general and specialized levels, educational planning for the required disciplines has been given priority in the National Bylaw for the Development of Palliative and Supportive Cancer Care (2012), and it has been proposed to develop an educational curriculum, as well as short-term and long-term course requirements, and to issue certificates by the deputy and office of continuing education in the health professions [21].

Cultural elements affect the patients’ reactions to being diagnosed with serious diseases such as cancer and the decisions they make about end-of-life care. Studies conducted on this subject identify three fundamental dimensions for end-of-life care and treatment as affected by cultural issues, including the manner of breaking “bad news,” the locus of decision-making about treatment procedures, i.e., resort to the available options or discontinuing treatment, and people’s attitudes toward end-of-life care [31].

Contrary to the emphasis in Western culture on truth-telling, in some cultures (such as in the Middle East, and more specifically, in Iran), it is not uncommon to hide the cancer diagnosis from the patient, and disclosure of cancer might be misconstrued as bad manners, disrespect, or even detrimental [31, 32]. For example, in Iran , in some cases, the patient might only learn about his disease long after his definitive diagnosis of cancer, and even then only indirectly through chancing upon his medical file, talking to other patients, starting treatments such as chemotherapy; under most circumstances, the diagnosis is not directly disclosed to the patient [33].

Although in many societies, decision-making is based on the patient’s autonomy and freedom to act, in some cultures, medical decisions are still doctor-oriented or doctor-family oriented, which might violate the patient’s autonomy. Some cultures (such as most Asian cultures) value the principle of productivity and usefulness more than autonomy and freedom to act. Consequently, in many of these cultures, care providers tend to hide cancer diagnoses from the patients. In such cultures, physicians obscurely express the severity of the patient’s condition by using medical jargon, and only disclose the information to the patient’s family members [31, 34]. In these cultures, the majority of people believe it a pointless cruelty to tell the patient directly that he has cancer [35]. In some Asian cultures (such as in Pakistan), the patient’s family members deliberately and actively protect him from the burden of finding out about his end-of-life conditions. In these cultures, disease is mostly a family event rather than a personal one, and it is often preferable if the family takes care of the patient (particularly during the end-of-life stage) [36].