Stillman et al.

Globalization and Health 2012, 8:34

http://www.globalizationandhealth.com/content/8/1/34

RESEARCH Open Access

Cancer registries in four provinces in Turkey:

a case study
Frances A Stillman1*, Michelle R Kaufman1, Naseeb Kibria1, Sultan Eser2, Mark Spires1 and Yusuf Pustu3

Abstract
Background: The burden of cancer affects all countries; while high-income countries have the capacity and
resources to establish comprehensive cancer control programs, low and middle-income countries have limited
resources to develop such programs. This paper examines factors associated with the development of cancer
registries in four provinces in Turkey. It looks at the progress made by these registries, the challenges they faced, and
the lessons learned. Other countries with similar resources can benefit from the lessons identified in this case study.
Methods: A mix of qualitative case study methods including key informant interviews, document review and
questionnaires was used.
Results: This case study showed that surveillance systems that accurately report current cancer-related data are
essential components of a country’s comprehensive cancer control program. At the initial stages, Turkey established
one cancer registry with international support, which was used as a model for other registries. The Ministry of Health
recognized the value of the registry data and its contribution to the country’s cancer control program and is
supporting sustainability of these registries as a result.
Conclusions: This study demonstrates how Turkey was able to use resources from multiple sources to enhance its
population based cancer registry system in four provinces. With renewed international interest in non-communicable
diseases and cancer following the 2011 UN high-level meeting on NCDs, low- and middle- income countries can
benefit from Turkey’s experience. Other countries can utilize lessons learned from Turkey as they address cancer burden
and establish their own registries.
Keywords: Cancer surveillance, Turkey, Case study, International collaboration, Cancer registry

Background 58.22, urging Member States to conduct cancer control

The global burden of cancer has increased over the and prevention activities [7,8]. A key provision in the
years, resulting in 7.6 million deaths in 2008, with an Resolution was to develop a comprehensive national
estimated two-thirds in low- and middle-income coun- cancer control programme and integrate it into a coun-
tries (LMICs) [1]. At this rate, an estimated 13 million try’s existing health care system. The WHO resolution
deaths are expected to result from cancer by 2030. also states that all countries committed to alleviating the
Although cancer is associated with more deaths than burden of cancer, regardless of their resource level,
HIV/AIDS in resource-poor countries [2], it is frequently should aim to implement a surveillance system [9].
classified into a broader category with other diseases in
many of these countries, as well as on the international
community’s health care agenda [3-6]. Although cancer Cancer registries in low to middle income countries
control efforts seem to be obscure in the current global “Cancer surveillance is the ongoing, timely, and system-
health agenda, in 2005 the World Health Organization atic collection and analysis of information on new cancer
(WHO) passed the Resolution on Cancer Control WHA cases, extent of disease, screening tests, treatment, sur-
vival, and cancer deaths” [10]. Surveillance systems,
including cancer registries, allow countries to obtain
* Correspondence: fstillma@jhsph.edu
1
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
specific data by geographic region on people diagnosed
Full list of author information is available at the end of the article with cancer and to use the data to develop preventive,
© 2012 Stillman et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Stillman et al. Globalization and Health 2012, 8:34 Page 2 of 8
http://www.globalizationandhealth.com/content/8/1/34

diagnostic, or therapeutic practices; to assess the efficacy Methods

of these interventions and initiate research studies; and This research used a qualitative case study approach to
to develop policies and allocate funding [10-12]. Cancer detail the process of expanding Turkey’s cancer regis-
registries that are set up throughout a country to collect tries. Data were collected from November 2010-January
and record data and report cancer cases in the areas 2011. Johns Hopkins Institutional Review Board approval
they cover are the foundation of cancer surveillance was obtained prior to data collection.
activities. However, it has been acknowledged that there
is a “significant lack of relevant cancer data from deve- Data collected
loping countries” [12,13]. Registries require time, effort, Qualitative data collection included reviews of the regis-
expertise and skills development so they can become tries’ background documents and online documents
functional and meet international standards. LMIC often from the Turkey’s MOH Cancer Control Department
lack cancer registries or “the cancer registration data website, organizational surveys, and in-person, in-depth
may be of low quality” [13]. Thus, it is important to gain key informant interviews. The documents reviewed pro-
a better understanding of the capacity and factors that vided information related to the formation of the regis-
could help develop and improve country cancer regis- tries and information concerning the registries’ capacity.
tries. In trying to establish cancer registries, LMICs often This background information was used to help in the
struggle with inadequate health services, transient development of the questions for the key informant
populations, lack of funding and of trained personnel, interviews and for the organizational survey (described
and incomplete or inaccurate data [14-18]. Turkey, an further below). Document review was limited to those
upper-middle-income economy [19], experienced many appearing in English, from both print and online
of these issues in establishing its first active population- sources. Additional background information was
based cancer registry. gathered from individuals outside Turkey with long-
standing knowledge of the registries, and this assisted
in the development of the topics to be included in inter-
Selection of Turkey for the case study view guides for the key informant interviews [Dr.
The Pfizer Global Health Partnership (GHP) project pro- Brenda Edwards, personal communication; Dr. Joe
vided funding to 31 countries, focusing on innovative Harford, personal communication]. Project staff from
cancer - and tobacco control programs [20]. One of the SUVAK reviewed the interview guides to ensure cultural
grants was to The New Hope in Health Foundation appropriateness. All interviews were conducted in
(SUVAK), a nongovernmental organization working with English; translation for non-English speakers was pro-
the Turkish Ministry of Health (MOH), to expand and vided by SUVAK. The key informant interviews (n=10)
enhance cancer registries in the provinces of Izmir, were conducted in person in Turkey and included
Antalya, Samsun, and Erzurum. Another objective was to SUVAK officials, MOH representatives, registry person-
establish a cancer advocacy network. Funding began in nel, and advocacy network representatives.
2008, and since these registries were at different stages of Finally, an organizational survey was conducted with
their development with varying levels of capacity, funds each registry. Open-ended questions were used to obtain
were used to improve the infrastructure and build the information on organizational structure and capacity, in-
capacity for these cancer registries as needed. The focus cluding information on registry personnel; staff skill devel-
was to improve quality control, hire and train additional opment; data collection (methods used, data quality
staff, provide additional training on how to identify and assurance methods, and other procedures used to update
review cases, and proper techniques in re-abstracting. or improve data collection); data usage (to whom and how
While registries were supported by government funds, disseminated); current funding sources; participation in
money was not available for travel, training and the re- international activities (meetings and publications); and
view process. Pfizer funding was used for these additional challenges/barriers faced by the registry.
costs needed to improve and enhance the registries.
While there are numerous registries in Turkey, this case Analysis
study will focus on the active, population-based registries Interviews were digitally recorded and transcribed. Sur-
that were included in the GHP project (Izmir, Antalya, vey data (open-ended questions) and interview data were
Samsun, and Erzurum). These registries provide an inter- content-analyzed using Atlas.ti 5.5 software to identify
esting account of the challenges they faced and the les- factors related to registry functioning and progress.
sons learned from which other countries with similar Other survey data was categorized and summarized.
resources can benefit; and it examines the contribution Representative phrases and quotations from the surveys
of these registries to the country’s overall cancer control and key informant interviews were selected to highlight
strategy. the identified factors. The following factors will be
Stillman et al. Globalization and Health 2012, 8:34 Page 3 of 8
http://www.globalizationandhealth.com/content/8/1/34

addressed: 1) establishment of the cancer registries in country. Furthermore, a number of the registries reported
Turkey; 2) organizational structure of the registries; 3) lack of skilled staff, and this is especially acute in Erzurum
enhancement of the registries; 4) using data to inform where turnover is higher and the registry has the fewest
policy; and 5) funding and sustainability. number of staff due to its lower level of development.
The Izmir Cancer Registry was the country’s first
Results population-based registry that supported active data col-
Establishment of cancer registries in Turkey lection [21,22]. It was initiated as a collaboration be-
This first registry in Turkey was established in Izmir in tween the University of Massachusetts in the United
1992. This registry became a member of WHO/Inter- States and the Ege University of Izmir. At first, the regis-
national Agency for Research on Cancer’s (IARC) Inter- try lacked the basic infrastructure, but it received both
national Association of Cancer Registries in 1995 and direct and indirect support from numerous international
the European Network of Cancer Registries (ENCR) in agencies, including the International Agency for Re-
1997 and was included within the framework of the search on Cancer (IARC) and the International Associ-
Middle East Cancer Consortium (MECC) in 2004 [21]. ation of Cancer Registries (IACR). Currently, in addition
This demonstrates that this registry was meeting inter- to the Izmir, Antalya, Samsun and Erzurum registries,
national standards with high quality, publishable and there are four other functional registries covering 21% of
representative data [22,23]. Other Turkish provinces the entire population. Data collected by these registries
worked to establish their cancer registries with Izmir as provide comprehensive understanding of cancer types
its model, often with varying degrees of success in being and patterns that differ by region and are used to formu-
able to produce the necessary level of quality data. late Turkey’s cancer projections [24,25].
As the registries were established at different times, they The interviews indicated that lack of resources is one
have varying levels of capacity. The amount of time the of the major challenges faced when establishing a regis-
registries have been in existence does reflect on their pro- try, but that interaction with cancer registries at the
gress to date, but there are other factors that influence their international level helped (Director, Izmir Cancer Regis-
current success. Table 1 compares basic information on try). For Turkey, getting the Izmir registry to be recog-
each of the registries in the study that could have such an nized by international agencies was extremely important.
influence. Location is an especially relevant issue since the The Izmir Registry was identified as a model program,
registries included in this study represent different areas of and this helped lead the way for others in the country.
the country. Izmir is in the West, Antalya is in the South, One MOH Official said, “. . ..we had a good model in
Samsun is in the North, and Erzurum is in the East. For ex- Izmir Cancer Registry and we tried to apply this model
ample, the Erzurum registry struggled initially and still has to other provinces we selected”. Thus, with the growing
not achieved international quality data, but it is deemed success of the Izmir Registry, the MOH decided to ex-
important for continued support and funding by MOH. pand the number of active registries in other regions of
This is largely due to the fact that Eastern Turkey is less Turkey to gather more population-based cancer data.
developed, has different cancer rates, and these data are The registry in the southwestern province of Antalya
needed to provide a comprehensive view of this area of the was established next, with the MOH working with such

Table 1 Comparative look at cancer registries in four provinces of Turkey

Province Year Local advisory Staff Ongoing International International Specific
(region covered) established committee capacity trainings quality journal barriers
for staff data publications
Izmir (Western Turkey) 1992 Yes 32 full time; Yes Yes Yes ● Current bureaucratic set-up
10 part time
● Missing mortality data
● Lack of staff
Antalya (Southern Turkey) 1995 Yes 10 full time; Yes Yes No ● Missing demographic data
42 part time
● Incomplete SEER staging data
Samsun(Northern Turkey) 2001 Yes 16 full time; Yes No No ● Some passive data
12 part time collection methods
● Missing demographic
Erzurum (Eastern Turkey) 2005 Yes 7 full time; Yes No No ● Inadequate access
2 part time to laboratories
● Missing demographic data
● Lack of staff
Stillman et al. Globalization and Health 2012, 8:34 Page 4 of 8
http://www.globalizationandhealth.com/content/8/1/34

local stakeholders as elected officials and healthcare pro- time personnel. Data are collected from a number of
fessionals. Developing a strong working relationship with district- level hospitals and other health care facilities. Dif-
these stakeholders as well as gaining local commitment ferences may exist due to differing bureaucratic structures
and support was a factor identified as contributing to the found with in the Provincial Health Directorates.
progress made by the Antalya registry. “There is good
ground level support from [the] medical community as Presence of qualified leadership and personnel
well as local leaders such as the mayor”(MOH official). Involved and committed leadership led to the success of
During subsequent years, additional registries were the Izmir Cancer Registry and its demonstration that
established, however; several registries failed to succeed. a strong champion from within can advocate with vari-
“The main reason of the failure [of a registry] is lack of en- ous stakeholders for a registry’s progress. The current
thusiasm of the local health authorities about the subject. Director of the Izmir Cancer Registry – a physician– has
[There were] problems in the organization of the regis- been with the project since its initiation and contributed
tries, lack of qualified personnel, lack of the registries’ in- towards establishing successful registries in Turkey.
frastructure, neglect of both the national and local Under her leadership, and with the funding provided by
administrators on the registries....” (MOH official). In the GHP, the Izmir registry has served as the model for
2000, the MOH convened the National Cancer Advisory other registries, and staff from Antalya, Samsun, and
Board of Turkey to provide overall direction to the coun- Erzurum and other registries have trained at Izmir.
try’s cancer registries. With advice from the Board, data According to the Director of the Izmir registry, in
were collected only from certain provinces. An MOH offi- addition to the staff coming to Izmir for training, Izmir
cial indicated that, “After 2000, we decided to collect data staff themselves travel to the other registries to help them
from certain provinces instead of the whole of Turkey be- improve their data abstracting and quality control
cause we noticed that it was very difficult. . . it’s quite im- procedures.
possible to collect reliable information from the whole of Another factor identified is the lack of trained
[a] country for 70 million people. So we decided to select personnel to lead and staff the registries. Having a com-
provinces and collect data”. mitted individual in the leadership role is especially im-
portant. Lack of leadership is one reason that the
Organizational structure of the registries Erzurum Cancer Registry has made slower progress. The
The four registries in our case study have a similar struc- interviews indicated that not being able to find a medical
ture. The MOH provides oversight of the Provincial Health doctor and finding and training someone only to have
Directorate or Agency regulating the Provincial Cancer them leave are significant and ongoing challenges that
Registry. Thus, the registries are administrated through the are faced. An explanation for this turnover, according to
Provincial Health Directorate and not at a national level. a key informant, was better professional opportunities in
Figure 1 shows the structural schematic of the Turkish can- other Turkish provinces. In addition to strong leadership,
cer registries. Each registry has a central office operating as a registry needs qualified staff to function optimally.
the core administrative body gathering data from numerous
hospital-based “cancer registry units”. Each registry in Enhancement of the registries Once the registries have
Turkey has core staff plus registrars and other full- and part- the infrastructure in place, ongoing staff training is

Figure 1 Administrative oversight of Provincial Cancer Control Registries in Turkey [24].

Stillman et al. Globalization and Health 2012, 8:34 Page 5 of 8
http://www.globalizationandhealth.com/content/8/1/34

essential to collect quality data and achieve the inter- Cancer Registry are included in IARC’s GLOBOCAN
national standards set by IARC. project that reports global cancer statistics; GLOBOCAN
also cites registry data from Antalya. Data from both
Ongoing trainings these registries are referenced in IARC’s publication,
Izmir registry was the model and helped provide the “Cancer Incidence in Five Continents Vol. IX”, highlight-
training for the other registries through site visits. Cur- ing again the quality of the data collected by these two
riculum included basic training, advanced training, geo- registries [28]. Registry personnel in Turkey have pub-
graphic mapping (GIS), and CANREG – the software lished research studies in peer-reviewed international
from IARC. The focus of these site visits was to improve journals, written book chapters, and spoken and pre-
quality control, hire and train additional staff, and pro- sented both domestically and in other countries, raising
vide additional training on how to identify and review their international profile and ensuring continued sup-
cases and proper techniques in re-abstracting. Since port from the international community.
registry personnel need specialized skills to collect com-
prehensive data and analyze and present accurate Using data to inform policies Using the quality data
results, systematic trainings organized by MOH and collected by the registries, Turkey was able to shape pol-
SUVAK to establish credentials is necessary. Ongoing icies and allocate funding and other resources towards
meetings where registry personnel discuss how to im- preventive measures [29]. For example, lung cancer is
prove data quality and conduct audits as quality control the most common type of cancer in males in Turkey
measures are also training opportunities. Registrars at- [23,25], and in 2009, the MOH took steps towards pre-
tend international conferences to network with cancer venting tobacco consumption by banning smoking in all
registry experts from other countries and to present indoor public places [29].
their research findings before the international commu- When the MOH Cancer Control Department presented
nity. While, these opportunities are important to build data obtained from cancer registries as a subset of over-
expertise and skills, they require resources that are not arching chronic diseases data, their MOH colleagues
always available. recognized and began to respect the cancer registries as
models to be replicated for other health projects adminis-
Maintaining quality data tered by the Ministry, as illustrated by this quote from a
To produce and maintain high-quality data, cancer regis- MOH official, “Cancer statistics became important for the
tries must perform quality assurance activities, as incom- Ministry and even became [a] model for other statistics”.
plete or missing data will lead to faulty projections and More importantly, cancer is now firmly in the forefront of
failure to detect patterns. In Samsun, initial audits showed the Turkish health agenda. There is now a realization that
the collected data were not accurate, but further training non-communicable diseases and chronic disease are be-
of registry staff, with technical assistance and site visits coming national priorities “Turkey finished this fight with
from experts, corrected this problem. Teams from other acute diseases; we do not have so much maternal deaths,
provinces with better success at collecting quality data almost 100 percent vaccination rate we now have. . .It is
were also sent by MOH to help. Erzurum has been the time for Turkey to fight chronic disease”. (MOH Official).
focus of some of these efforts, with the result being that
clear data trends have begun to emerge and progress is Funding and sustainability When the Izmir registry’s
being made. For all the registries, including Izmir, the data met the international criteria established for quality,
model registry and ongoing audits are necessary to main- it won the support of the MOH. Most of the registries’
tain and enhance data quality. funding support comes from the MOH, while the re-
mainder is a mix of international health organizations,
International collaboration and recognition corporations, and private philanthropic organizations.
Over the years, the Izmir Cancer Registry has achieved With the GHP funds in particular, SUVAK and the
success partly because of assistance from MECC [21]. MOH were able to train additional registry personnel.
MECC, with support from the U.S. National Cancer In- Since government funds cannot be used for certain ac-
stitute (NCI) of the National Institutes of Health, assists tivities such as attending international meetings, the
in establishing and enhancing population-based cancer GHP funds defrayed some of the associated costs. As the
registries in its member countries [26,27]. MECC pro- Izmir and the Antalya registries were already established,
vides funds and technical assistance to the Izmir Cancer these external funds were used to upgrade the infra-
Registry, contributing to its growth and success, with structure and conduct audits.
three full-time registrars paid through MECC funds. For cancer registries – as for any other program – to be
Coupled with this, another indicator of Izmir’s success successful and develop over time, they must demonstrate
is its international recognition. Data from the Izmir sustainability once international donors have pulled back.
Stillman et al. Globalization and Health 2012, 8:34 Page 6 of 8
http://www.globalizationandhealth.com/content/8/1/34

In Turkey, a testament to the credibility and sustainability cancer control program. It outlines the real life struggles
of the registries is that the MOH now provides the majority the registry workforce and the ministry officials faced at
of their funding support, as international partners are the initial stages and how they were overcome. It pro-
slowly stepping away. “[The] Ministry recognized the im- vides a summary of the difficulties that can potentially
portance of the registries and provided additional funding be avoided by other countries with limited resources.
and supported setting up of additional of registries” (MOH The registries we highlight in this case study found that
Official). location (and thus level of development), proper staffing,
With the government firmly committed to supporting and varying levels of capacity were challenges that
the registries, they will adapt and sustain themselves needed to be addressed to bring other registries up to
using existing resources. The MOH also recognizes the par. But with sufficient funding and support from inter-
importance of building a qualified workforce to support national organizations, the registries were able to over-
these registries in the longer term. Providing adequate come these barriers, establish successful registries, and
compensation to attract and retain qualified profes- gain recognition of the importance of cancer surveillance
sionals is essential to maintain these registries. by the MOH.
For LMICs establishing a population-based registry, hav-
“If you want to get real benefit from a project. . .the ing government-issued policies in place could be benefi-
human resources and manpower is the most important cial, as in Turkey [30,31]. Health care professionals are
thing for this project, but you have to pay enough more likely to respond to government-mandated direc-
money. Otherwise, it is impossible to get qualified tives on data reporting than to requests from the registries
persons and human resource” (MOH official). themselves. Key factors for gaining wider support and ac-
ceptance include demonstrating: 1) the government’s sup-
Overall functioning of the registries needs to be port through the presence of such policies or directives,
streamlined for sustainability. As key informants noted, and 2) the value of the data collected by the cancer regis-
the current multi-layered bureaucratic structure of the tries. In this study, convincing the MOH was the first step
cancer registries prevents regular contact between regis- to making this happen. But with Turkey’s success as a role
try staff and the policy-making government agency. model for other countries, this could perhaps be achieved
Interaction is also limited between the staff and other more quickly for other countries.
qualified professionals, which discourages collaboration Turkey faced many challenges in establishing and
with the international registry community. Regular inter- expanding its cancer registries. Its lessons are useful for
action between these various stakeholders can lead to other countries with limited resources to begin develop-
more efficient and effective registry operation. ing effective registries. According to key informants, set-
ting up registries was time-intensive, but often certain
Creation of an advocacy network A unique feature stakeholders wanted a new registry created quickly to
that may contribute to long-term registry success could collect quality data and function efficiently. Educating
be the creation of an advocacy network in Turkey. officials on the importance of building the capacity and
SUVAK brought a number of disparate organizations technical skills of the registry staff – a process which,
under a single platform called “Hand in Hand Against according to IARC, takes several years – is an important
Cancer”, and, with GHP funding support, organized a initial step. This is clear in the case of Turkey, and could
capacity-building training series for these NGOs to em- be used as an example of the often-lengthy process for
power and unify them towards a shared vision. The key other countries that expect too much in too short a time.
informants indicated that,“. . .in Turkey we don’t have Informant interviews also revealed how physicians and
enough NGO activities, so we are very hungry for that other potential registry workforce perceived cancer
kind of project”. The network has developed resources to registrars. Initially, it was difficult to attract qualified
build the public’s cancer awareness and educate them. candidates to this field, as it was undervalued as a career
More importantly, it has given a voice to those most choice. However, with growing national and inter-
affected by cancer and has presented their work to the national recognition, that perception is changing; the
Turkish Parliament. The network has the capacity to MOH and other stakeholders understand the value of
translate data collected by the registries for advocacy building a qualified workforce and providing adequate
purposes and to push cancer into the country’s main- compensation. Again, these lessons learned in Turkey
stream health agenda. could serve as guiding principles for other countries look-
ing to establish their own registries.
Discussion The provincial cancer registries in Turkey are cur-
This study illustrates the trials and tribulations of Turkey rently administered by a multi-layered bureaucratic
as it established cancer registries and expanded their structure that prevents free interaction between registry
Stillman et al. Globalization and Health 2012, 8:34 Page 7 of 8
http://www.globalizationandhealth.com/content/8/1/34

staff, researchers from outside organizations, and policy Received: 30 April 2012 Accepted: 17 October 2012
makers. Key informants recommended moving the regis- Published: 30 October 2012

tries under the umbrella of a national research institu-

tion to circumvent some of the bureaucracy; this could References
1. International Agency for Research on Cancer: World Cancer Report 2008.
also allow registry personnel to operate more indepen- Lyon, France: IARC; 2008.
dently. This is a lesson learned that could benefit 2. World Health Organization: The global burden of disease: 2004 update.
countries who are looking to establish registries in the Geneva, Switzerland: WHO Press; 2004.
3. Boyle P, Anderson BO, Anderson LC: Need for global action for cancer
near future. control. Ann Oncol 2008, 19(9):1519–1521.
It should be noted that currently a limitation faced by 4. UN Millennium Project: Investing in Development: A Practical Plan to Achieve
Turkey is that mortality data is not collected, and this the Millennium Development Goals. New York: 2005. http://www.
unmillenniumproject.org/reports/fullreport.htm.
restricts the comprehensiveness of its registry data. In 5. Hanna TP, Kangolle AC: Cancer control in developing countries: using
accordance with international standards, Turkey is health data and health services research to measure and improve
implementing new legislation requiring all family physi- access, quality and efficiency. BMC.Int Health Hum Rights 2010, 10:24.
6. World Health Organization: Action plan for the global strategy for the
cians to complete a cause-of-death form that includes prevention and control of noncommunicable diseases. Geneva Switzerland:
cancer mortality data. The MOH also plans to collect WHO; 2011.
cancer survival data. It is recommended that countries 7. World Health Organization: Resolution on cancer prevention and control,
WHA 58:22. 2005. cited 2011 Apr 13] Available from http://www.who.int/
that use Turkey as a model for establishing cancer regis- cancer/media/news/WHA58%2022-en.pdfv.
tries take this limitation into account when establishing 8. World Health Organization. National Cancer Control Programmes: Policies
their own mechanisms. and managerial guidelines. Geneva, Switzerland: WHO Press; 2002.
9. Draft political declaration of the high-level meeting of the general assembly on
the prevention and control of non-communicable diseases. 2011. [cited 2011
Sept 26] Available from http://www.un.org/en/ga/ncdmeeting2011/pdf/
Conclusion NCD_draft_political_declaration.pdf.
This study demonstrates how Turkey used resources from 10. National Cancer Institute: Surveillance, Epidemiology and End Results.
multiple sources to enhance its population-based cancer Accessed at http://seer.cancer.gov/index.html on March 6, 2012.
11. Armstrong BK: The role of the cancer registry in cancer control.
registry system in four provinces. With renewed inter- Cancer Causes Control 1992, 3(6):569–579.
national interest in non-communicable diseases and can- 12. Reeler AV, Mellstedt H: Cancer in developing countries: challenges and
cer following the 2011 UN high-level meeting on NCDs, solutions. Ann Oncol 2006, 17(Supplement 8):viii7–viii8. symposium article
doi:10.1093/annonc/mdl981.
low- and middle- income countries can benefit from Tur- 13. Curado MP, Voti L, Sortino-Rachou AM: Cancer registration data and
key’s experience. Other countries can utilize lessons quality indicators in low and middle income countries: their
learned from Turkey as they address cancer burden within interpretation and potential use for the improvement of cancer care.
Cancer Causes Control 2009, 20(5):751–756. p1.
their own borders and establish their own registries, learn- 14. Jensen OM, Whelan S: Planning a cancer registry. In Cancer registration:
ing from each other to create a world that has a better principles and methods. Edited by Jensen OM, Parkin DM, Maclennan R.
handle on this serious threat to global health. Lyon, France: IARC Publications; 1991:22–28.
15. Parkin DM: The role of cancer registries in cancer control. In Cancer
registration: principles and methods. Edited by Jensen OM, Parkin DM,
Competing interests Maclennan R. Lyon, France: IARC Publications; 1991:102–111.
The authors declare that they have no competing interests. 16. Institute of Medicine: The cancer burden in Low- and middle- income
countries and How It is measured. In Cancer control opportunities in Low
Authors’ contributions and middle income countries. Edited by Sloan F, Gelband H. Washington, DC:
National Academy Press; 2007:69–105.
FS –designed and conceptualized the case study, collected the data, helped
in interpretation of the data, provided the structure for the paper, and 17. Valsecchi MG, Steliarova-Foucher E: Cancer registration in developing
prepared the final draft of the paper. MK –helped with the data analysis, countries: luxury or necessity? Lancet Oncol 2008, 9(2):159–167.
helped with the interpretation of the data and writing of the manuscript. 18. Parkin DM: The evolution of the population-based cancer registry.
Nat Rev Cancer 2006, 6(8):603–612.
NK–conducted the analysis and wrote the 1st draft of the paper. SE-
provided data for the case study, helped in interpretation of the findings, 19. The World Bank and Country Lending Groups. 2011. cited 2011 Jul 6]
and reviewed and contributed to the writing of the paper. Available from http://data.worldbank.org/about/country-classifications/
MS –helped in designing the data collection instruments, helped with the country-and-lending-groups.
20. Working together to create a world without cancer: global strategies that
data collection, and contributed to writing and reviewing the paper. YP-
assisted with data collection and review and contributed to the content of advance cancer and tobacco control efforts. Mid-term report of the Global
the paper. All authors read and approved the final manuscript. Health Partnerships. 2011. cited 2011 Apr 13] Available from http://www.
jhsph.edu/bin/s/m/GHP%20Compendium.pdf.
21. Middle East Cancer Consortium. http://mecc.cancer.gov/.
Acknowledgements 22. Fidaner C, Eser SY, Parkin DM: Incidence in Izmir in 1993–1994: first results
This manuscript was funded through a grant from the Pfizer Foundation for from Izmir cancer registry. Eur J Cancer 2001, 37(1):83–92.
their Global Health Partnerships program. The authors would like to thank 23. Eser S, Yakut C, Ozdemir R, et al: Cancer incidence rates in Turkey in 2006:
Drs. Brenda Edwards and Joe Hartford from the National Cancer Institute for a detailed registry based estimation. Asian Pac J Cancer Prev 2010,
their input on this paper. 11(6):1731–1739.
24. Cancer Control in Turkey: Republic Of Turkey Ministry of Health. In Cancer
Author details Control Department. Edited by Murat Yuncer A. Ankara: Ministry Publication
1
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Number 777; 2010. ISBN 978 -975- 590-300-2.
2
Izmir Cancer Registry, Izmir, Turkey. 3New Hope in Health Foundation 25. Yilmaz HH, Yazihan N, Tunca D, et al: Cancer trends and incidence and
(SUVAK), Ankara, Turkey. mortality patterns in Turkey. Jpn J Clin Oncol 2011, 41(1):10–16.
Stillman et al. Globalization and Health 2012, 8:34 Page 8 of 8
http://www.globalizationandhealth.com/content/8/1/34

26. Harford JB, Edwards BK, Nandakumar A, Ndom P, Capocaccia R, Coleman

MP: ICCC-3 Session A Group. Cancer control-planning and monitoring
population-based systems. Tumori 2009, 95(5):568–578.
27. Freedman LS, Edwards BK, Ries LAG: Overview and summary data. 2006.
cited 2011 Jul 6]; Pub. No. 06–5873:1–27. Available from http://seer.cancer.
28. IARC: In Cancer incidence in five continents Vol. IX. Edited by Curado MP,
Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, Boyle P: IARC Scientific
Publication No.160; 2007. http://www.iarc.fr/en/publications/pdfs-online/epi/
sp160/index.php.
29. Bilir N, Cakir B, Dagli E: Tobacco control in turkey. Copenhagen, Denmark:
WHO Regional Office for Europe; 2009.
30. Farmer P, Frenk J, Knaul FM, et al: Expansion of cancer care and control in
countries of low and middle income: a call to action. Lancet 2010,
2(376):1186–1193.
31. Braithwaite D, Wernli KJ, Anton-Culver H, Engstrom P, Greenberg ER, Meyskens F:
Opportunities for cancer epidemiology and control in low- and middle-
income countries: a report from the American Society For Preventive
Oncology International Cancer Prevention Interest Group. Cancer Epidemiol
Biomarkers Prev 2010, 19(7):1665–1667.

doi:10.1186/1744-8603-8-34
Cite this article as: Stillman et al.: Cancer registries in four provinces in
Turkey: a case study. Globalization and Health 2012 8:34.

Submit your next manuscript to BioMed Central

and take full advantage of:

• Convenient online submission

• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution

Submit your manuscript at

www.biomedcentral.com/submit