Oncology stewardship: A narrative review of principles and practices

IntroductionThe rising costs, complexity, and ethical challenges of anticancer therapies have created an urgent need for structured frameworks to ensure clinical efficacy, cost-effectiveness, and equitable access. Oncology stewardship (OS) has emerged as a promising model to optimize oncology pharmacotherapy and resource allocation. However, the lack of a unified model for OS implementation and evaluation represents a critical gap. This review addresses this by synthesizing emerging practices and policy considerations to inform the structured integration of OS into oncology systems.MethodsThis narrative review followed the conceptual synthesis approach outlined by Baumeister & Leary (1997) and Green et al. (2006), to develop a coherent understanding of OS as a clinical and policy framework. English-language sources published between 2001 and 2025 were purposively selected from PubMed, Scopus, and Google Scholar. Thematic analysis was used to organize and interpret findings.ResultsFive core domains were identified: (1) systemic drivers necessitating OS, including rising costs, drug shortages, safety concerns, and ethical considerations; (2) core operational strategies such as pre-authorization, dose optimization, site-of-care transitions, biosimilar adoption, and biomarker-guided therapy; (3) the governance role of Pharmacy and Therapeutics Committees in formulary management and clinical decision-making; (4) structural components and outcome metrics to assess the clinical, economic, and operational impact of OS; and (5) implementation barriers such as stakeholder resistance, limited infrastructure, and regulatory gaps. The review also highlights that although many OS initiatives demonstrate clinical and financial promise, their success is often limited by voluntary, fragmented implementation and a lack of standardized evaluation.ConclusionOS offers a critical but underutilized framework for improving the quality, safety, and sustainability of oncology care. While several operational models and interventions have shown promise, their fragmented adoption and weak regulatory support hinder scalability. Advancing OS will require national-level policy integration, investment in implementation infrastructure, and the development of standardized metrics to guide evaluation and accountability.