Crystal S. Denlinger, MD, serves as CEO at the National Comprehensive Cancer Network® (NCCN®), where she oversees the development of evidence-based, expert consensus-driven clinical practice guidelines that shape cancer care across the United States and globally. A practicing medical oncologist with approximately 20 years of clinical experience, Denlinger brings firsthand insight into the complexities of modern cancer treatment delivery.
Please begin with an outline introduction to NCCN’s mission and the role you have in shaping clinical decision-making through your guidelines.
Our mission is quite simple but very profound: to define and advance quality, effective, equitable, and accessible cancer care and prevention so that all people can live better lives. We include in our mission both cancer care and prevention because we develop cancer-related resources for the healthcare community that span the entire spectrum of care from screening, early detection, and risk assessment all the way through diagnosis, treatment, and into survivorship and rest of life. We address not only cancer-related diagnoses but all of the supportive care and special considerations that one might have within specific populations.
The basis of what we do is the NCCN Clinical Practice Guidelines in Oncology (or NCCN Guidelines®), which are evidence-based, expert consensus-driven recommendations spanning the entire care continuum. Building on those guidelines, we develop a range of related resources that translate this information for different stakeholders. For example, we offer patient guidelines that take the clinical practice recommendations and present them in patient-friendly, person-first language. In addition, we maintain searchable databases of our recommendations – the Library of Compendia – which allow users to access specific guidance along with supporting documentation. We also develop tools for education and care delivery that support knowledge generation on how best to deliver cancer care.
We also have programmes that help further cancer care and best practices through a variety of mechanisms. One is our Oncology Research Program, which supports peer-reviewed, funded cancer research and knowledge sharing. We publish the peer-reviewed Journal of the National Comprehensive Cancer Network, or JNCCN, which allows for dissemination of both the NCCN Guidelines information as well as original peer-reviewed articles. We also offer a series of continuing education programmes both online and in person, that have triple accreditation for physicians, nurses, and pharmacists. Taken together, these initiatives form a comprehensive suite of resources for oncology providers, as well as for those who are interested in learning more about oncology.
In terms of our role in shaping oncology decision-making, we are a resource for clinicians at the point of care around the world. The guidelines are free for non-commercial use and can be used during cancer care delivery in clinic, but can also be used as a resource for research to understand what current appropriate care looks like, and for payers and policymakers as well. The guidelines form the basis for oncology coverage policy within the US, and both the guidelines and related resources are used by CMS and most major payers to support their decision-making around coverage and provide reference material to support the safe delivery of drugs and biologics used in cancer care.
How do your activities and guidelines reflect the contemporary needs of clinicians, patients, and other stakeholders?
I am still a practising medical oncologist, so I understand, to some degree, what is required to deliver high-quality care. First and foremost, clinicians need up-to-date, trusted information that is easily accessible. We are committed to ensuring that our resources are updated in a timely manner and continue to reflect the most appropriate recommendations, grounded in the best available evidence and expertise in the field.
Having been in practice for about 20 years, it is very clear that over time cancer care has become increasingly complex, more specialised, and more niche, as our understanding of disease biology and subtypes has deepened. Our guideline panels fully recognise this evolution. The experts who serve on these panels continuously evaluate the rapidly evolving evidence to ensure that recommendations reflect optimal care based on the best evidence currently available. As a result, clinicians using our guidelines effectively have the collective expertise of our 33 Member Institutions at their fingertips.
One of the things we also recognise is that as evidence grows and innovation accelerates, cancer care becomes more complex, and the guidelines themselves inevitably become more complex, particularly in their traditional PDF format. In response, we developed the NCCN Guidelines Navigator, a digitised version of the clinical practice guidelines designed to simplify complex treatment algorithms and provide greater clarity and continuity for a patient-specific pathway, while remaining firmly anchored within the broader guideline framework. Within this platform, we have integrated several related resources and created streamlined access points to our full suite of tools. This allows clinicians to more easily identify the most appropriate treatment pathway for the specific patient in front of them and to quickly access supporting materials, such as the Principles pages of the Guidelines or the relevant chemotherapy order templates, enabling them to deliver care safely, efficiently, and comprehensively.
At the same time, we operate in an environment with an ever-expanding number of information sources, making it increasingly difficult to know which information can be trusted. This challenge is particularly acute for individuals facing a cancer diagnosis, who may search online and be confronted with an overwhelming and often conflicting array of content. The NCCN Guidelines for Patients are designed to address this gap by providing patients and caregivers with trusted information that mirrors what healthcare providers receive through the clinical practice guidelines, but in a format optimised for patient and caregiver understanding.
These free resources support people as they navigate cancer-related decisions, enabling them to engage more knowledgeably in discussions with their physicians. Ultimately, this improves the likelihood of making well-informed, goal-concordant, and person-centred decisions. By providing information in formats tailored to different stakeholders – whether patients and caregivers, clinicians, industry, policymakers, or the general public – we ensure that everyone is working from the same evidence base, which in turn supports better decision-making and better care overall.
How does NCCN keep pace with rapid innovation while ensuring its guidelines remain both evidence-based and practical for everyday clinical use?
In the course of my career, I have seen the introduction of targeted therapies for colon and rectal cancer with initial monoclonal antibodies. Now there are at least 10 different considerations that we have to think about for determining the most appropriate therapy for a newly diagnosed person with metastatic colon cancer. This is just one example. I have seen the rapid pace of innovation firsthand.
NCCN is committed to updating our clinical practice guideline library at least annually, reflecting the rapid pace of innovation and the continuous evolution of new evidence. This is a commitment we have maintained since our inception 30 years ago. Recognising that patients and caregivers need the same information in a timely manner, we will align our patient guideline library with this schedule from January 2026, moving from updates every one to three years to a consistent annual cycle alongside the clinical practice guidelines. While we are committed to annual updates, the rapid pace of change in oncology often requires more frequent revisions. Beyond the scheduled yearly meeting, our clinicians review new evidence, FDA approvals, and emerging data as it becomes available, evaluating how it should be incorporated and contextualised within the current guidelines.
Our panels take this process seriously. They recognise that our guidelines do not just play a role at the academic tertiary cancer centre, but they also play a role for the community oncologist. I would argue they might be even more important for the community oncologist who is treating more patients in the community and may not necessarily be able to attend as many academic meetings. Because of that, the panellists work to ensure that the recommendations can be implemented not just at the big academic tertiary cancer centres but also in the community where the majority of cancer care is delivered.
The other thing I think is important is that each guideline panel has at least one representative from each Member Institution, and 95 percent of our panels have a patient advocate on them as well, who has the same voice as the Member Institution representatives and the same vote. We do not just take into account the clinicians’ point of view and the multidisciplinary teams’ point of view, but we also take into account the patient voice. Each one of those panel representatives is charged with overseeing an institutional review process where the guidelines get circulated to the multidisciplinary teams at each of their institutions for comment and review, and those institutional comments come back as part of the annual review process for evaluation. The panellists also look at all of the new evidence as it evolves and think about how to better contextualise these innovations that are emerging within the overall landscape of care delivery.
Beyond clinical practice, to what extent are the guidelines also used within making at the payer level?
The guidelines provide a roadmap for appropriate care from screening through survivorship and provide a framework for how available resources should be utilised and how evidence should be integrated into the landscape. This can provide not just clinicians but also payers and policymakers with information regarding what appropriate care should look like, so it provides context for every one of our stakeholders in the oncology landscape.
By creating not only the guidelines but also resources that make recommendations easily accessible to different stakeholders, we ensure payers have the same information as clinicians. For example, our Library of Compendia is a searchable database covering drugs, biologics, biomarkers, radiation therapy, and imaging. Most payers use these Compendia to inform their coverage decisions, as they reflect the guideline recommendations directly.
One other point I want to make is that there is a body of evidence out there that has demonstrated that delivering guideline-concordant care is associated with improved outcomes. That includes improved overall survival, improved quality of life, lower cost both to the entire health system as well as out-of-pocket costs, and decreased disparities. As we think about how to ensure coverage policy allows equitable access to everyone, the way to do that is to ensure that we can make the right thing easy and possible through guideline-concordant coverage.
As a clinician, what do you see as the biggest gaps in the US system today in translating innovation into appropriate, accessible care?
We still see areas where guideline-concordant care is not reaching everyone who needs it, for many reasons. Because following guidelines improves outcomes, we must ensure access for all, align coverage policies with recommendations, reach patients in underserved areas, and provide the resources they need to navigate a complex healthcare system.
We are starting to see these gaps close with the growing implementation of patient navigation – services that are now being reimbursed and increasingly integrated across the full care continuum, not just at entry. We are also making clinical trials more inclusive through decentralisation, reaching patients far from major academic centres, and raising awareness of the importance of broad representation so trial evidence applies to everyone receiving care.
Ensuring that people are aware of what these recommendations are, ensuring that people are aware of what best practices are to allow for accessible care through things like navigation and inclusive clinical trial enrolment. Those are things that can help ensure that the ecosystem can be better responsive to the needs of those who are facing a cancer diagnosis. I think it is important that we ensure that the best care for each individual patient or person is easily accessible and aligns with what the evidence supports.
NCCN works with leading academic centres that are highly innovative and well-resourced. How are best practices from these centres translated into community care settings across the US, and how are the differences between these settings considered when developing the guidelines?
NCCN is an alliance of 33 leading cancer institutions across the country, including both free-standing and matrix university cancer centres. One of our strengths is the diversity of our Member Institutions who have different capabilities, catchment areas, and foci. Some centres serve rural populations across large geographic areas, others serve urban populations with diverse socioeconomic backgrounds, and some engage in global cancer care in collaboration with institutions worldwide.
This breadth of experience informs guideline recommendations and highlights areas of best practice. Our institutions lead discussions on care delivery through in-person and hybrid educational events. For example, our annual conference covers not only clinical updates and therapeutic strategies but also sessions on best practices in care delivery. Similarly, our recent policy summit on the unique needs of first responders and veterans began with a session translating practices from academic centres into community settings.
Through our Oncology Research Program, we fund grants focused on quality improvement in care delivery and disseminate those learnings broadly. NCCN’s expertise also extends globally through tools like the NCCN Framework for Resource Stratification (NCCN Framework™), which provides guidance on delivering care across different resource settings and can be applied both internationally and domestically.
Finally, we collaborate with regional experts worldwide to adapt guidelines to local needs, considering metabolic, regulatory, and access differences. This ensures that recommendations remain aligned with the parent guideline while meeting the specific needs of clinicians and patients globally.
Considering payers, policymakers, clinicians, and industry, how do you see the full range of cancer stakeholders working together to make sure that innovation and clinical guidelines keep pace with new developments, while still being practical and sustainable for everyday care?
This has been an exciting and unprecedented time in cancer care. It reflects the community’s consistent investment in research to better understand cancer biology and the ability to harness that knowledge to develop more effective treatments and truly person-centred care. This progress is possible because all stakeholders are aligned. Organisations like ours collaborate with professional bodies, patient advocacy groups, industry, policymakers, and payers. By working together with a focus on patient-centred care, we can take rapid advances and translate them into improved outcomes.
We are seeing this in rising overall survival rates and the declining cancer death rate in the United States. This progress comes from turning innovation into everyday practice. To continue advancing, we must keep collaborating, investing in research, generating evidence through clinical trials, and exploring innovative questions. These efforts will define the next generation of effective therapies.
Equally important is ensuring that policies supporting care delivery align with best practices and the best available evidence. All stakeholders need the right information to translate and contextualise innovation in clinical practice. As I said earlier, we must make doing the right thing the easiest thing. By aligning systems with guideline concordance and supporting evidence generation, we can deliver high-quality, sustainable, goal-concordant, and patient-centred care for everyone.
What final message would you like to deliver on behalf of the NCCN to the cancer care community?
NCCN recognises that cancer touches everybody, whether you are diagnosed yourself or a loved one with cancer. Everyone knows someone who has had to think about cancer at some point in their life. As a community, we need to continue to work together to ensure that all people, regardless of where they are located, receive high-quality, high-value, person-centred care.
NCCN works and exists to achieve this goal. Our guidelines and the resources that are derived from those guidelines, all of which are available at nccn.org, can help ensure that all of the stakeholders within the oncology landscape have access to the same trusted, evidence-based information in a way that is accessible and easy for them to use. It is when we work together as a community that we can ultimately achieve great things in oncology.
As somebody who has been in the field for 20 years, I have seen that evolution and progress, and I am excited to be in oncology now because I think we are just starting to see what is possible. I am excited about what we can do together as a community, but it means all of us working together to ensure that everyone receives the best possible care for them.
