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The standard of care is the treatment that guidelines and experts currently consider the best-proven option.
The standard of care is the treatment that guidelines and expert consensus currently regard as the best-proven option; SoC, standard therapy, standard regimen and guideline-concordant care are its aliases. It is defined by NCCN, ESMO and ASCO guidelines on the basis of randomised evidence, shifts with each positive phase 3 trial, and varies by region according to approvals and reimbursement. The term is linked to the NCCN Guidelines collection, the National Comprehensive Cancer Network (NCCN), the NCCN Compendium and Nathan Cherny. It runs through the bottlenecks on slow trial enrolment, regulatory divergence, prices and value, fragmented care, slow knowledge diffusion and misaligned incentives, and it underpins the idea that sponsors must justify every exclusion criterion.
Patients with limited-stage small-cell lung cancer who complete chemoradiotherapy without progression should now be offered up to two years of durvalumab consolidation, which extends life by almost two years on average. This is the first survival improvement for limited-stage disease since twice-daily radiotherapy and prophylactic cranial irradiation, and small-cell lung cancer is no longer a disease where immunotherapy gives only marginal gains.
Almost every patient newly diagnosed with advanced bladder or urothelial cancer should now be offered enfortumab vedotin plus pembrolizumab rather than chemotherapy, with median survival extended from about 16 months to over two and a half years. Neuropathy and skin toxicity need monitoring and dose adjustment, and patients with severe diabetes or pre-existing neuropathy need care. Platinum chemotherapy remains an option for those who cannot receive the combination.
The survival gain turns the earlier progression-free survival result into a clear reason to offer pembrolizumab with and after chemoradiotherapy to women with node-positive or stage III-IVA cervical cancer. Because cervical cancer is concentrated in low- and middle-income countries, the benefit reaches most women only if pricing and access follow.
Women with locally advanced cervical cancer that is node-positive or stage III-IVA can be offered pembrolizumab alongside and after chemoradiotherapy to lower the chance of relapse. The result matters most in countries where cervical cancer is common but immunotherapy access is poorest, so its global impact depends on pricing and health-system capacity. It does not apply to early-stage disease treated with surgery or to lower-risk locally advanced disease without nodal involvement.
For fit patients with newly diagnosed metastatic pancreatic cancer, a FOLFIRINOX-type regimen is now proven to be better than gemcitabine plus nab-paclitaxel, settling a long-standing debate. The absolute gain is about two months of median survival, and the regimen is more toxic for the gut. Whether liposomal irinotecan adds anything over conventional irinotecan (standard FOLFIRINOX) has never been tested head-to-head.
Patients with advanced liver cancer and good liver function should be offered atezolizumab plus bevacizumab (or durvalumab plus tremelimumab) rather than sorafenib as first treatment; median survival is now around 19 months and about a quarter of patients respond. Endoscopy to treat varices before starting bevacizumab is essential because of bleeding risk. Patients with poorer liver function (Child-Pugh B) or autoimmune disease or transplants were not studied.
Patients with stage III lung cancer that cannot be removed surgically should receive a year of durvalumab after completing chemoradiotherapy, provided they have not progressed. This roughly doubles the chance of being alive without progression at five years. Whether the benefit extends to PD-L1-negative tumours is contested, and the EGFR-mutated subgroup is better served by osimertinib (LAURA).
Men diagnosed with prostate cancer that has already spread, or that is locally advanced and high risk, should start abiraterone (or another androgen-receptor pathway inhibitor) at the same time as testosterone suppression rather than waiting for resistance. This roughly halves the risk of death over several years. The same platform later showed that docetaxel chemotherapy and, in high-volume metastatic disease, triple therapy also help, and that abiraterone benefits men with high-risk disease treated with radiotherapy.
Shares NCCN Compendium and drug compendia, National Comprehensive Cancer Network (NCCN), Incentives reward me-too drugs and marginal gains, Fragmented care and guideline gaps.
Shares Control arm and comparator (investigator's choice), Placebo, Randomised trial, Phase 1, 2 and 3 trials.
Shares Pragmatic trial, Placebo, Randomised trial, Phase 1, 2 and 3 trials.
Shares ASCO clinical practice guidelines, Knowledge reaches practice too slowly, Incentives reward me-too drugs and marginal gains, Regulatory divergence between regions.
Shares Pragmatic trial, Randomised trial, Phase 1, 2 and 3 trials, Trials enrol too few, too slowly.
Shares ASCO clinical practice guidelines, Default-inclusive eligibility: sponsors must justify every exclusion criterion, Living, machine-readable guidelines pushed to the point of care in every country, Older and multimorbid patients are excluded and undertreated.
Shares NCCN Compendium and drug compendia, Off-label, Prices and value.
Shares NAPOLI-3: NALIRIFOX versus gemcitabine plus nab-paclitaxel as first treatment for metastatic pancreatic cancer, IMbrave150: atezolizumab plus bevacizumab replaces sorafenib as first treatment for advanced liver cancer, EV-302: enfortumab vedotin plus pembrolizumab replaces chemotherapy as first treatment for advanced bladder cancer, Incentives reward me-too drugs and marginal gains.