The research team set out to answer a deceptively simple question: if Iran were to launch a fully organized, population-based breast cancer screening program tomorrow, what would it need to fix first? To do this rigorously, the investigators designed a three-stage convergent mixed-methods study. In the first stage, they conducted a systematic literature review, screening 953 records and retaining seven high-quality studies from which they extracted the building blocks of an assessment checklist. This checklist covered the domains that international guidelines consider essential for organized screening: target population definition, invitation and recall systems, diagnostic follow-up, workforce and equipment, information systems, financing, and performance monitoring.

Because a checklist built from a handful of studies could miss locally relevant criteria, the researchers then convened a two-round Delphi panel of six experts to refine and validate the instrument. The Delphi technique, a structured consensus method in which experts score and comment on items across successive rounds until agreement stabilizes, allowed the team to merge international evidence with the practical judgment of Iranian policy makers and clinicians. Only after the checklist had been finalized and validated did the team apply it, drawing on the data gathered in the literature review together with six semi-structured interviews with policy makers, oncologists, and frontline healthcare providers who run screening services on the ground.

The picture that emerged is one of a system with real assets but weak connective tissue. Iran does have a national guideline for breast cancer screening, and it has a broad network of health centers and screening facilities distributed across the country. Trained personnel exist, and public awareness campaigns about breast cancer have been running for years. Yet implementation of screening remains inconsistent from province to province, with significant disparities in access, resource allocation, and program reach. In practice, most screening is opportunistic: women are examined when they happen to visit a health facility for another reason, rather than being systematically identified, invited, and followed up by the health system.

This distinction between opportunistic and organized screening is more than bureaucratic hair-splitting. In organized programs, the health system maintains a registry of the eligible population, issues personal invitations at prescribed intervals, tracks every woman who fails to attend, and monitors outcomes such as cancer detection rates and interval cancers. Opportunistic screening, by contrast, systematically misses women who are less likely to seek care, and it produces uneven quality because there is no mechanism to verify that examinations and mammography readings meet standards. The Iranian study found that key performance indicators, including early detection rates and follow-up completion rates, are not systematically monitored anywhere in the program, which makes it nearly impossible to know whether screening is actually saving lives or merely generating activity.

Technical and administrative weaknesses compound the problem. The researchers documented manual data management across much of the screening pathway, meaning that records of examinations, referrals, and diagnostic outcomes are often kept on paper or in disconnected local systems rather than in an integrated electronic registry. Without such a registry, no invitation-based program can function, because the system cannot know who is due for screening, who has been screened, and who needs recall for suspicious findings. The study also identified insufficient dedicated funding for screening as a persistent constraint, with resources for promotion, equipment maintenance, and follow-up competing against other priorities in health budgets that are not ring-fenced for cancer control.

The interviews with frontline providers and specialists added texture to these structural findings. Providers described the practical consequences of limited proactive outreach: women in remote and underserved provinces may live far from mammography facilities, may not receive any reminder that screening is due, and may encounter the health system only when symptoms appear, often at later and harder-to-treat stages. Policy makers acknowledged that although Iran’s primary health care network, one of the most extensive in the region, reaches deep into rural areas, that network has not been fully harnessed for systematic cancer screening in the way it has for maternal and child health or for the management of other non-communicable diseases through initiatives such as IraPEN, the Iranian package of essential non-communicable disease services.

What makes the study notable for health policy observers is that it does not simply catalog failures. The authors emphasize that Iran’s established infrastructure, trained personnel, and ongoing awareness campaigns constitute a strong foundation on which an organized program could be built relatively quickly. The country’s primary health care system already assigns populations to specific health houses and health centers, which is precisely the catchment structure that invitation-based screening requires. The missing elements are the information systems to register and track eligible women, sustainable and dedicated financing, continued workforce development in mammography technique and reading, and a monitoring framework with defined indicators that are routinely reported and acted upon.

As a feasible pathway forward, the study proposes piloting an invitation-based screening model in selected provinces or defined catchment areas before attempting national scale-up. This incremental approach mirrors the trajectory followed by many countries that successfully transitioned from opportunistic to organized mammography screening: demonstrate the model in a manageable setting, measure coverage and quality indicators, fix the operational problems that only appear in practice, and then expand. The authors argue that such pilots would generate the local evidence on costs, acceptance, and logistics needed to convince decision makers to invest in the integrated electronic systems and monitoring frameworks that a national program demands.

The stakes are considerable. Because breast cancer is the top cause of cancer death among Iranian women, and because survival depends strongly on the stage at which the disease is detected, the difference between a functioning organized screening program and an opportunistic one is measured in lives. The study, conducted as part of the first author’s PhD thesis in health policy and approved by the ethics committee of Tehran University of Medical Sciences, received no specific external funding and involved no competing interests. Its message to Iran’s health authorities is direct: the foundations are in place, the checklist for success has now been written and validated, and the next step is a deliberate, monitored shift from waiting for women to arrive to actively inviting them in.

Subject of Research: Situation analysis of the breast cancer screening system in Iran using a mixed-methods design

Article Title: Situation analysis of breast cancer screening in Iran: a mixed-methods study

Article References: Dorri Kafrani, S., Akbari Sari, A., Yunesian, M., Moadabshoar, L., & Daroudi, R. (2026). Situation analysis of breast cancer screening in Iran: a mixed-methods study. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-02991-z

Image Credits: AI Generated

DOI: 10.1186/s12939-026-02991-z

Keywords: breast cancer screening, Iran, organized screening, opportunistic screening, health system assessment, Delphi method, mammography, health equity, non-communicable diseases, screening policy, primary health care, mixed methods