{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T13:19:08Z","timestamp":1787663948969,"version":"build-2736575974"},"reference-count":31,"publisher":"Wiley","issue":"8","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":17,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cancer Medicine"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Colorectal cancer (CRC) is an emerging public health concern in Bhutan, a lower\u2010middle\u2010income country with a geographically challenging terrain and limited specialised oncology services. As the country undergoes an epidemiological and economic transition, CRC numbers are steadily increasing. While Bhutan has made progress in cancer control through national programmes, CRC has not been a priority cancer, and health system readiness for its screening and management remains unclear. This study aimed to assess CRC care delivery in Bhutan and identify systems gaps using the World Health Organisation's health system building blocks framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A qualitative study was conducted using semi\u2010structured interviews with key stakeholders involved in cancer care delivery. Interviews were conducted in person or via secure virtual platforms and analysed using inductive thematic analysis and deductive coding guided by the WHO health systems framework until thematic saturation was reached. A comprehensive document review of publicly available CRC\u2010relevant services was also performed to complement the interview data collected. In total, twenty stakeholders including clinicians, policymakers, nurses and traditional medical practitioners were interviewed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results and Discussion<\/jats:title>\n                    <jats:p>The results reflected key health system challenges including workforce shortages due to overseas migration, limited subspecialty training, and inadequate technical expertise within policymaking structures. Infrastructure constraints such as intermittent connectivity and power outages affected the functionality of the national electronic Patient Information System. CRC services remain highly centralised at tertiary hospitals, resulting in financial and geographic barriers for patients from remote districts. Medicine shortages, constrained health financing, and reliance on overseas referrals further limit service capacity. Sociocultural factors, including reliance on informal healers and delayed care\u2010seeking behaviours, also contribute to late presentations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Strengthening CRC care requires coordinated health system reforms and Bhutan's experience offers important lessons for small health systems seeking to strengthen cancer care amid resource constraints and complex sociopolitical contexts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient and Public Involvement Statement<\/jats:title>\n                    <jats:p>Neither patients nor the public were involved in the development, analysis or writing of this study.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/cam4.72179","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T03:04:07Z","timestamp":1787108647000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Colorectal Cancer in Bhutan: Identifying Health System Gaps and Priorities"],"prefix":"10.1002","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7254-4881","authenticated-orcid":false,"given":"Chuan De","family":"Foo","sequence":"first","affiliation":[{"name":"NUS Saw Swee Hock School of Public Health and National University Health System  Singapore Singapore"},{"name":"Duke NUS Medical School  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-9247-2651","authenticated-orcid":false,"given":"Sonam","family":"Yoezer","sequence":"additional","affiliation":[{"name":"Dechencholing Hospital Jigme Dorji Wangchuck National Referral Hospital  Thimphu Bhutan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tashi Dendup","family":"Wangdi","sequence":"additional","affiliation":[{"name":"Kidu Medical Centre Jigme Dorji Wangchuck National Referral Hospital  Thimphu Bhutan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prabhat","family":"Pradhan","sequence":"additional","affiliation":[{"name":"Jigme Dorji Wangchuck National Referral Hospital  Thimphu Bhutan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7119-4178","authenticated-orcid":false,"given":"Yun Le","family":"Linn","sequence":"additional","affiliation":[{"name":"Sengkang General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6790-902X","authenticated-orcid":false,"given":"Chong Tsung","family":"Wen","sequence":"additional","affiliation":[{"name":"Singapore General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elliot","family":"Eu","sequence":"additional","affiliation":[{"name":"Duke NUS Medical School  Singapore Singapore"},{"name":"Occupational and Environmental Medicine Department Singapore General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vanessa","family":"Yik","sequence":"additional","affiliation":[{"name":"Singapore General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia Lin","family":"Ng","sequence":"additional","affiliation":[{"name":"Sengkang General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeremy Tian Hui","family":"Tan","sequence":"additional","affiliation":[{"name":"Singapore General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fung Joon","family":"Foo","sequence":"additional","affiliation":[{"name":"Sengkang General Hospital  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2569-1261","authenticated-orcid":false,"given":"Evelyn","family":"Wong","sequence":"additional","affiliation":[{"name":"National Cancer Centre Singapore  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3299-2628","authenticated-orcid":false,"given":"Taufique","family":"Joarder","sequence":"additional","affiliation":[{"name":"SingHealth Duke\u2010NUS Global Health Institute Duke\u2010NUS Medical School  Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"e_1_2_17_2_1","doi-asserted-by":"publisher","DOI":"10.3322\/caac.21660"},{"key":"e_1_2_17_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.scib.2025.02.006"},{"key":"e_1_2_17_4_1","doi-asserted-by":"publisher","DOI":"10.1177\/10732748251378666"},{"key":"e_1_2_17_5_1","unstructured":"datadot https:\/\/data.who.int\/countries\/064."},{"key":"e_1_2_17_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.lansea.2024.100370"},{"key":"e_1_2_17_7_1","doi-asserted-by":"publisher","DOI":"10.1096\/fba.2020\u201000117"},{"key":"e_1_2_17_8_1","volume-title":"Cancer Care and Treatment Remain Centralised as Cases Rise Across Bhutan","author":"sangye","year":"2026"},{"key":"e_1_2_17_9_1","unstructured":"Bhutan Cancer Control Strategy (2019\u20132025) | ICCP Portal https:\/\/www.iccp\u2010portal.org\/resources\/bhutan\u2010cancer\u2010control\u2010strategy\u20102019\u20102025."},{"key":"e_1_2_17_10_1","unstructured":"Health Flagship Project \u2013 MOH https:\/\/moh.gov.bt\/pages\/health\u2010flagship\u2010project\/."},{"key":"e_1_2_17_11_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12885\u2010025\u201015037\u20104"},{"key":"e_1_2_17_12_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13690\u2010017\u20100221\u20109"},{"key":"e_1_2_17_13_1","doi-asserted-by":"publisher","DOI":"10.1191\/1478088706qp063oa"},{"key":"e_1_2_17_14_1","unstructured":"World Bank Blogs Can Internet Access Lead to Improved Economic Outcomes https:\/\/blogs.worldbank.org\/en\/digital\u2010development\/can\u2010internet\u2010access\u2010lead\u2010improved\u2010economic\u2010outcomes."},{"key":"e_1_2_17_15_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurpub\/ckac129.691"},{"key":"e_1_2_17_16_1","unstructured":"Global Maps of Travel Time to Healthcare Facilities | Nature Medicine https:\/\/www.nature.com\/articles\/s41591\u2010020\u20101059\u20101."},{"key":"e_1_2_17_17_1","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.ED000157"},{"key":"e_1_2_17_18_1","doi-asserted-by":"publisher","DOI":"10.4103\/2224\u20103151.264850"},{"key":"e_1_2_17_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2214\u2010109X(14)70373\u20100"},{"key":"e_1_2_17_20_1","doi-asserted-by":"publisher","DOI":"10.4269\/ajtmh.20\u20101416"},{"key":"e_1_2_17_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.lanepe.2025.101326"},{"key":"e_1_2_17_22_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.lansea.2024.100489"},{"key":"e_1_2_17_23_1","doi-asserted-by":"publisher","DOI":"10.47176\/mjiri.39.115"},{"key":"e_1_2_17_24_1","volume-title":"Private Clinics Doing Well in Thimphu","year":"2019"},{"key":"e_1_2_17_25_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh\u20102023\u2010013408"},{"key":"e_1_2_17_26_1","volume-title":"Rising Concerns Over Unauthorized Medical Practices and Quackery in Bhutan","year":"2025"},{"key":"e_1_2_17_27_1","doi-asserted-by":"publisher","DOI":"10.4102\/curationis.v38i2.1495"},{"key":"e_1_2_17_28_1","unstructured":"Bhutan Cancer Society Empowerment Through Knowledge and Hope https:\/\/www.bcs.org.bt\/."},{"key":"e_1_2_17_29_1","doi-asserted-by":"publisher","DOI":"10.1007\/978-981-99-7842-7_218"},{"key":"e_1_2_17_30_1","doi-asserted-by":"publisher","DOI":"10.3332\/ecancer.2026.2071"},{"key":"e_1_2_17_31_1","doi-asserted-by":"publisher","DOI":"10.1200\/GO\u201025\u201000412"},{"key":"e_1_2_17_32_1","doi-asserted-by":"publisher","DOI":"10.1596\/978-1-4648-0349-9_ch16"}],"container-title":["Cancer Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/cam4.72179","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/cam4.72179","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/cam4.72179","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T12:25:22Z","timestamp":1787660722000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/cam4.72179"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":31,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1002\/cam4.72179"],"URL":"https:\/\/doi.org\/10.1002\/cam4.72179","archive":["Portico"],"relation":{},"ISSN":["2045-7634","2045-7634"],"issn-type":[{"value":"2045-7634","type":"print"},{"value":"2045-7634","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]},"assertion":[{"value":"2026-04-03","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-06","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-18","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e72179"}}