Fragmented Governance Emerges as the Core Barrier to Cancer Care in Iran’s Family Physician System

Cancer rarely announces itself at the door of an oncology ward. For most patients, the journey begins in a clinic, often with a family physician who is the first—and sometimes the only—point of continuity in a long and fragmented path through prevention, diagnosis, treatment, and supportive care. A new qualitative study from Iran argues that this first point of contact is precisely where cancer care management succeeds or fails, and that the deepest problems are not clinical at all but structural: fragmented governance and unclear stewardship sit upstream of nearly every difficulty patients and providers encounter along the cancer care pathway.

The research, published in BMC Cancer, was conducted by Seyed-Amir Soltani, Ghahraman Mahmoudi, Mohammad-Ali Jahani, and Jamshid Yazdani-Charati, a team spanning health services administration, social determinants of health research, and biostatistics at institutions including Islamic Azad University in Sari and Babol University of Medical Sciences. Their goal was ambitious but specific: to build an explanatory model describing how cancer care could actually be organized and managed within Iran’s urban family physician system, drawing on the lived experience of the people who run, staff, and govern that system every day.

To do this, the team turned to grounded theory, a qualitative methodology designed to generate explanatory frameworks from data rather than to test pre-existing hypotheses. Between 2025 and 2026, the researchers recruited thirty-six stakeholders through purposive sampling, later extended by theoretical sampling—a technique in which emerging findings guide the selection of subsequent participants until no new conceptual material surfaces. The participant pool deliberately cut across the entire hierarchy of cancer care: family physicians working at the front line, clinical specialists treating the disease, healthcare managers running facilities, policymakers shaping the system, and faculty members training the workforce.

Data collection relied on individual semi-structured interviews, a format that gives participants room to describe their experiences in their own terms while still allowing the interviewer to probe specific themes. The interviews were then analyzed using MAXQDA 2020 software and the classic three-stage coding sequence of grounded theory. In open coding, the raw interview text was broken down into 122 initial codes—the smallest conceptual units of meaning. Axial coding then grouped these codes into 18 subcategories by exploring the relationships between them, and selective coding finally distilled the whole dataset into 7 main categories organized around a single core category that anchored the entire model.

That core category reads like a thesis statement for the whole study: developing integrated and coordinated cancer care within the urban family physician system. In other words, when the researchers asked what the system most fundamentally needed, the answer was not more equipment, more specialists, or more funding in isolation, but coordination—deliberate, governed, continuous linkage between the levels of care through which every cancer patient must pass. Theoretical saturation, the point at which new interviews stop generating new categories or relationships, was assessed through the progressive development and refinement of these categories, and the study’s rigor was checked against established qualitative trustworthiness criteria.

The architecture of the resulting model is causal and layered. At the top sit fragmented governance and unclear stewardship—upstream conditions that the authors identify as the root of the problem. Because no single authority clearly owns the cancer care pathway, the downstream machinery of the system suffers: organizational capacity remains limited, referral coordination between primary and specialized care breaks down, health information systems fail to integrate, and continuity of care erodes as patients move between providers. These four mechanisms, in turn, shape the concrete challenges that surface across the entire cancer continuum—prevention, early detection, treatment coordination, supportive care, and patient engagement.

This layered logic matters because it reframes where reform efforts should aim. If the model is correct, then patching individual service deficiencies—say, improving screening uptake in one district or shortening wait times at one hospital—will produce only local and temporary gains, because the upstream governance conditions that generated the dysfunction remain untouched. Effective cancer care management, the authors conclude, depends on strengthening coordination across healthcare levels rather than addressing isolated weaknesses one at a time. The finding carries a pointed message for health ministries everywhere that have invested heavily in vertical, disease-specific programs while leaving the connective tissue between primary and specialist care underdeveloped.

The Iranian context gives the study particular weight. Iran has spent years strengthening its primary healthcare network, and the family physician program is a central pillar of that effort, intended to serve as the gatekeeper and coordinator for urban populations. Yet cancer, as the researchers note, demands coordinated and continuous services across prevention, diagnosis, treatment, and supportive care—demands that stretch a gatekeeping model to its limits when referral pathways are unclear and information does not travel with the patient. The study’s doctoral-dissertation origins at Islamic Azad University, Sari, and its ethics approval under code IR.IAU.SARI.REC.1404.116, with written informed consent from all participants, situate it within a formal research program aimed squarely at improving health services administration in the country.

Methodologically, the study illustrates why qualitative designs remain indispensable in health services research. Randomized trials can tell us whether a drug works; they cannot tell us why a referral letter never arrives, why a family physician hesitates to initiate cancer screening, or why a policymaker’s directive dissolves somewhere between the ministry and the clinic. Grounded theory, applied rigorously with constant comparison across interviews and software-supported coding, is built to surface exactly those mechanisms. By triangulating the perspectives of physicians, specialists, managers, policymakers, and academics, the researchers captured the system as a web of interacting roles rather than a single actor’s viewpoint—a perspective that quantitative indicators of cancer outcomes alone could never provide.

The practical implications are correspondingly structural. The authors point to evidence-informed opportunities for improving governance structures, referral pathways, information integration, and continuity of cancer care within primary healthcare settings. Each of these corresponds to a mechanism in the model, and each would require stewardship—clear ownership of the cancer pathway—to implement. For a global community increasingly focused on universal health coverage and the burden of noncommunicable disease, the study offers a transferable lesson: the family physician’s office is not merely the cheapest place to see a patient, but potentially the most powerful node in the entire cancer care network, provided the governance exists to connect it to everything downstream. Published open access on 9 October 2026 with the DOI 10.1186/s12885-026-16790-w, the research invites health systems researchers and policymakers alike to stop treating coordination as an afterthought and start treating it as the core category of cancer care itself.

Subject of Research: Cancer care management within the urban family physician system in Iran

Article Title: Elucidating an explanatory model for cancer care management within the urban family physician setting in Iran: a qualitative grounded theory study

Article References: Soltani, S.-A., Mahmoudi, G., Jahani, M.-A., & Yazdani-Charati, J. (2026). Elucidating an explanatory model for cancer care management within the urban family physician setting in Iran: a qualitative grounded theory study. BMC Cancer. https://doi.org/10.1186/s12885-026-16790-w

Image Credits: AI Generated

DOI: 10.1186/s12885-026-16790-w

Keywords: cancer care management, family physician, primary health care, grounded theory, qualitative research, health governance, referral coordination, continuity of care, Iran, health services administration, BMC Cancer, integrated care