1. Afyon Kocatepe University, Department of Family Medicine, Turkey,
2. Afyon Kocatepe University, Department of Biostatistics, Turkey,
3. Afyon Kocatepe University, Department of Internal Medicine, Turkey

Corresspondence to:
Dilek Toprak, MD
Department of Family Medicine
Afyon Kocatepe University,
Afyonkarahisar 03200, TURKEY
Telephone number : 0090 532 3827836
Fax number : 0090 272 2132907
E-mail : dilekt66@yahoo.com

Cancer is a serious growing problem worldwide, especially a disease of the developing world. It is not only a biological processes it is also the outcome of lifestyle decisions and social conditions. So we need to understand what causes cancer at the biological and social levels but also what cancer causes to the families, to the people living with a person who has cancer.

Based on the World Cancer Report there were 10.1 million new cases, 6.2 million deaths and 22.4 million persons living with cancer in the year 2000. It is second to cardiovascular disease as a cause of death in developed countries and the number of new cases is expected to grow by 50% over the next 20 years, to reach 15 million by 2020⁽¹⁾. In 2006, in Europe, there were an estimated 3,191,600 cancer cases diagnosed (excluding non-melanoma skin cancers) and 1,703,000 deaths from cancer⁽²⁾. Cancer is an important problem in both public health and political terms worldwide, irrespective of a country's development.

Cancer arises out of conditions of life, which result in exposure to carcinogens.We can argue about two factors on this subject:

• Changes people make in the world
  
• Where people live
  

We know that there are social factors in cancer etiology, which include socioeconomic status, occupation (industrial hazards), radiation, medications, habits, food handling, air and water pollution.
These social dimensions of cancer have important implications for the design of cancer control programming. They stem from behavior patterns that people evolve to meet their biological, psychological and social needs. These patterns, in turn, create a lifestyle which influences cancer incidence. They include the development of addictions to tobacco, drugs and alcohol, the ways in which food is prepared, stored and eaten, and certain other risk patterns.

The disease is widely feared around the world over as synonymous with suffering and death. Patients may be stigmatized and experience social isolation and family tensions as well as the inability to get insurance or even job loss with economic dependence aggravated by high costs of medical care, if there is no health insurance. This condition also causes changes in lifestyle of the families involved.

As a result cancer impacts not only on the patient, but also his or her family and community. The aim of our study was to assess how many people have cancer patients (living or deceased) in their homes, in our city; the types of cancers, and their relationship with living places and economic status.

The study was conducted in Afyonkarahisar, a middle Anatolian city, between November 2005 and February 2006. The present study was approved by the Afyon Kocatepe University Faculty of Medicine Clinical Research Ethics Committee and written, informed consent was obtained from all participants.

A total of 2035 people, from 75 different screening regions (18 urban, 57 villages) of our city were detected according to the population records of the year 2000, which represent the population of the area appropriately. A total of 7000 km. roadway driven for the research by a team of 15 physicians, 1 nurse and a driver. The records of the regional health institutions were used in order to determine the subjects. People older than 18 years old were grouped as 19-40 years old, 41-64 years old, 65 and over. According to population distribution of year 2000, we determined the minimum number of people as 1990 (when d=0.02) and at the end of the study we reached a number of 2035 people. The study group selected randomly from the "Family Cards" of the primary health centers, regarding the gender and ages. Only one person was selected from every house.

The subjects were informed about the study by telephone interviews one night before, their approvals were obtained and their transport to the health institutions, where the study would be conducted, was provided. The data were collected by a questionnaire in which face to face survey method was performed by the physicians. As this study is a part of a big epidemiological research study only the question about cancer (Is there a person with cancer or who has died from cancer) was regarded and its relations with economic status and living place have been evaluated. Also type of cancer was asked about.

The data of the study was written in SPSS 12.0 version. Statistical evaluation of the study was performed using the chi-square test and p values lower than 0.05 were accepted as significant.

We found that there were 333 (16.4%) people who had a history of a patient who had died from cancer in their home and 100 (4.9%) people living together with a cancer patient. So in total, 19.71% (n=401) of our study group were living or/and had lived before with cancer patients in their homes. Also people living in urban areas have more living (odds ratio=1.45) and deceased (odds ratio=1.28) cancer patients in their homes than people living in villages. According to economic status; 75.2% of total study group had low income, which was similar (76.81%) in cancer patients' families. The distribution of these people regarding the living place and economic status has been shown in Table 1 and 2.

The most common cancer types among 333 dead cancer patients was lung cancer (n=114, 34.2%), stomach cancer (n=30, 9.0%), colon cancer (n=24, 7.21%), larynx (n=22, 6.61%) and leukemia/ lymphoma (n=21, 6.31%) respectively. Gender distribution of the first 5 common cancer types, among 333 died cancer patients is shown in Table 3.

The living cancer patients were mostly suffering from lung cancer (n=18, 18.0%) of which 83.3% (n=13) were men, larynx cancer (n=13, 13.0%), breast cancer (n=13, 13.0%), prostate cancer (n=9, 9.0%) and leukemia/ lymphoma (n=9, 9.0%) respectively. Gender distribution of the first 5 common cancer types, among 100 living cancer patients is shown in Table 4. Also the gender distribution of both living and dead cancer patients are listed in Table 5.

Regarding all the study group (n=2035) the most prevalent cancers were lung cancer (n=132, 6.49%), gastric cancer (n=37, 1.82%), larynx cancer (n=35,1.72%), colon cancer (n=30, 1.47%), leukemia/ lymphoma (n=30, 1.47%) and breast cancer (n=29, 1.43%), respectively.

In our study we founda total 19.71% (n=401) families who were affected by cancer, either living with a cancer patient and/or cancer death. This result also approximately showed the cancer rate of our city, which meant one of five families is affected by a type of cancer. As it is mentioned in WHO's World Cancer Report; worldwide, twelve percent of people die from cancer and in industrialized countries more than one in four will die from the disease which means each of us will experience grief and pain as a result of cancer, as a patient, a family member or a friend (1). In a study by Boyle et al it has found that one in four to one in five North Americans will die of cancer and in countries with a westernised lifestyle about half of all deaths are caused by circulatory disease and a quarter by cancer⁽³⁾.

In this study, we found lung cancer as the most common cancer type causing death and it is also the most prevalent cancer in our region. Lung cancer as the most common death causing cancer, is similar with many other studies, but the total number of cases changes according to the country. In American Cancer Society reports, the most common cancer deaths in both genders has seen lung cancer numbers decline but it is the second highest level of cancer cases⁽⁴⁾. In 2007, the most common form of cancer was breast cancer (429,900 cases, 13.5% of all cancer cases), followed by colorectal cancers (412,900, 12.9%) and lung cancer (386,300, 12.1%); while in 2004, lung cancer was the most common cancer in Europe, followed by colorectal cancer (13.2%) and breast cancer (13%)^(5,6).

In another study in Portugal the most frequent cancer among men in 2000 was cancer of the colorectum followed by cancers of the prostate, lung, stomach and urinary bladder. In women, breast cancer was the most common cancer followed by cancers of the colorectum, stomach and corpus uteri⁽⁷⁾.

According to our study the probable reason of high prevalence of lung cancer in men is high smoking rates in our population, which is directly related with lung cancer. In a study in our region the smoking prevalence (including ex-smokers) is 36%; which is 74.4% in men and 8.7% in women⁽⁸⁾. In a report by the Turkish Minister of Health it is indicated that the most common cancer in our country is lung cancer (17.6%) and it was guessed that 30,000 - 40,000 people die from lung cancer every year⁽⁹⁾. Regarding a study in Turkey, the smoking prevalence among 15 and over aged population is 43% (63% in men, 24% in women), which is really a big danger for lung cancer⁽¹⁰⁾. We can confirm the increasing trend of lung cancer as there is an increase in smoking among women. Lung cancer and several other forms of cancer, could be diminished by improved tobacco control. Also the lung cancer rates were particularly high in much of Eastern Europe reflecting current and past tobacco smoking habits of many of its inhabitants⁽⁶⁾. By widespread use of screening tests, carrying out big projections about controlling cancer can lower the rates. This kind of study can reduce the traumatic effects of cancer on the families who are mostly responsible for the care of cancer patients.

In many countries all over the world among women, breast cancer is the most prevalent cancer like our results^(4,6,11,12). But we have to pay attention to lung cancer in women also because of increasing smoking prevalence in our country.

Cancer causes 1/20 of deaths in developing countries and ¼ of all deaths in developed countries. This means it is the second commonest cause of death after cardiovascular disease. Thus most individuals in the world have some experience of the disease, if not personally, then in a family member, friend or acquaintance. Cancer remains an important public health problem also in Turkey, and we think the ageing of our population and high smoking prevalence will cause these cancer numbers to continue to increase.

Thus regarding our results many individuals in our region have some experience of cancer whether suffering themself from cancer or a cancer patient in their home. We think this brings a social health expectation of education about homecare of cancer patients. At the present time, neither the government nor the private sector properly provide reimbursement for homecare in Turkey or there are only limited numbers of homecare services which are only in big cities and given by private health services. In most of the regions, families and the patients have serious health promotion gaps. Relatives try to provide care at home to those people with cancer. None of the hospitals are providing home care in an organized or official way. We, as health staff, have to pay attention to this subject and help the families and make big projects about homecare of cancer patients.

The education of the relatives or the caregivers of cancer patients is so important and can probably be done by a family physician who is responsible for the social, psychological and biological health of the members and the family. In a study by Jones LE et al, it is shown that primary care utilization in the early phase of cancer treatment has a marked effect that results in a reduced mortality risk in patients with incident lung cancer⁽¹³⁾. In another study by McAvoy BR et al among 210 organisations 42% provided cancer education and training. As a result of good adult education practice 95% of organisations ran accredited programs⁽¹⁴⁾. So with funding support and well-structured organizations primary care professionals can play a critical role in cancer care.

The primary caregivers' evaluation of caring for a terminally ill patient at home in conjunction with a home palliative care service were both high and positive⁽¹⁵⁾. The National Strategy Document for Cancer in the Republic of Ireland proposes that cancer treatment services should be centered around primary care services, regional services and supra-regional centers⁽¹⁶⁾.

Like tobacco prevention (especially focused on the male population), diet and physical activity (risk factors for colorectal cancer) concerning should be the main subjects of family educations by primary care servers.
The next stage of our study can be the social and psychological affects of living with cancer patients on the families; the effect of education and giving information services to families about cancer.

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