Reviewing a Decade of Oncology Pathways: Standardization, Gaps, and the Road to Real-Time Intelligence

At this year’s Clinical Pathways Congress and Cancer Care Business Exchange (CPC+CBEx) conference, Linda Bosserman, MD, PhD, FASCO, FACP, medical director of value based care and the Center for International Medicine for the City of Hope, and David Jackman, MD, medical director of clinical pathways at the Dana-Farber Cancer Institute, led a timely update on oncology pathways. The speakers surveyed how far the field has come in a decade since the original American Society of Clinical Oncology (ASCO) guidance and where it still struggles to meet evolving clinical needs. Drawing from a set of 2023 surveys across payer groups, vendors, and major oncology practices, their session examined how pathways are developed, implemented, and analyzed—and what’s missing from the current state of play.

“This is an update on oncology pathways from the major US stakeholders,” Bosserman opened. “What are people doing? How are they developed? What are the implementation steps? And what analytics are being used?”

The session synthesized data and insights from 9 organizations representing 3 stakeholder types: payers, vendors, and large group practices.

The field has expanded dramatically since pathways first emerged as tools for standardizing oncology care and improving value. Among the organizations surveyed, 4 now cover 40 or more diseases, while others span 20 to 39. However, variation remains in depth and scope—especially for rare cancers.

“The rarer the cancer, the less likely you [are to] remember all the details,” Bosserman said. “That’s not the best way we want to practice medicine.”

While all 9 respondents cover the most common solid tumors (eg, breast, colon, prostate), diseases such as small bowel, thymoma, and peritoneal mesothelioma are addressed in only 1 or 2 pathways. Hematologic malignancies show similar disparities: all include B-cell lymphomas and myeloma, but only 1 covers myeloproliferative neoplasms, and 2 cover cutaneous lymphomas or amyloidosis.

Pathways also differ in how far they extend into lines of therapy. While all include metastatic first-line treatment, only 7 cover third line and beyond. In small-cell lung cancer, only 5 had third-line options despite US Food and Drug Administration (FDA) approvals existing at the time of the survey. As Jackman noted, “That’s not lack of expertise—it’s interpretation of evidence. These are the differences.”

Stakeholders showed differences in transparency and structure. Five of the 9 make pathway committee membership public, while 4 do not. All include community oncologists and pharmacists; 6 include academic physicians, but only 2 involve advanced practice providers. None included patient advocates.

Prioritization approaches vary. Some offer a single recommended option, while others present ranked or sequential choices. Six systems show treatment costs, but “what cost means” differs—some report wholesale acquisition cost (WAC), others use Centers for Medicare & Medicaid Services (CMS) Average Sales Price (ASP), or real-world data.

Pediatric oncology remains an underrepresented area. Only 1 pathway system includes pediatric pathways, and Bosserman noted that, “While pediatric oncology tends to be very cooperative, there hasn’t been a big push for pediatric pathways.”

Workflow integration is improving, but still uneven. Six of 9 respondents reported having pathways embedded directly into their electronic medical records (EMRs), and most of those allow selections to flow into treatment ordering systems. However, this requires extensive interfacing across regimens. As Jackman pointed out, “You need 1200 interfaces—one for each regimen.”

Clinical trial integration is also growing. Seven respondents include access to trials, with 4 integrating trials into treatment options and 3 offering separate tools. Only 2 allow direct access to full protocols.

City of Hope, Bosserman’s institution, offers a model for high compliance without rigid mandates. “We don’t require compliance; we require data entry,” she said. “Unless there’s something new, it’s rare to be off pathway. We want 80% alignment, but the choice is clinical.”

On analytics, most organizations can report on pathway adherence, off-pathway reasons, and breakdowns by disease, biomarker, or clinician. However, capabilities vary. Some systems allow self-service reporting, while others offer only centralized, customized reports.

Only 2 allow real-time embedded analytics. Most can track by line of therapy and disease, but stage- and biomarker-level tracking is less common. “Analytics is just as important as decision support,” Jackman emphasized. “We must ask: are we doing better?”

Reporting is also being used to highlight gaps in adoption. City of Hope, for example, tracks usage by site, physician, age, and biomarker to pinpoint disparities. “That’s value-based care power,” Bosserman said.

The panelists agreed that current systems are still largely static—and that the future must be dynamic. Real-time learning, artificial intelligence (AI) overlays, and predictive modeling are on the horizon.

“AI can overlay rich content, speed processes, and flag trials,” Bosserman explained. “We need ways to add new options without huge costs.”
Jackman echoed this vision: “Pathways today are still static. But real-world data shows subsets of patients that differ. AI plus real-world learning can make pathways dynamic and adaptive. That’s the future.”

He also emphasized that standardization is only the beginning. “Pathways cover the 99%. Complex case review, tumor boards, and colleague input handle the rest.”

The 2023 survey data reflect both maturation and fragmentation across the pathways landscape. While systems have expanded coverage, improved workflow integration, and invested in analytics, gaps remain—particularly in rare diseases, later lines of therapy, and real-time decision support.

“Pooling knowledge is critical,” Bosserman concluded. “By sharing expertise effectively, we ensure standards are solid—not siloed.”

As the field looks ahead, expanding disease coverage, integrating real-time analytics, and addressing operational burden will be essential steps toward achieving both clinical precision and operational efficiency.

“Precision care isn’t just molecular—it’s the whole patient,” Bosserman added. “That’s the next frontier.”

Reference 
Bosserman L, Jackman D. Innovative collaborations in oncology: bridging pathways, industry, and patient care. Presented at the Clinical Pathways Congress; September 6, 2025; Boston, MA.