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Departure from a gate default is permitted when anatomy, biology, organ function, comorbidity, access or patient goals make it unsuitable — the reason must be recorded. It is not a licence to substitute a lower-evidence modality for a proven curative option.
Intent is assigned before a device is chosen. Curative intent means an attempt to eradicate all known cancer; it does not establish a cure rate. Local control, complete radiographic response, complete pathologic necrosis in a treated lesion, and overall survival are four different outcomes.
Do not use a universal ablation → SBRT → Y-90 → TACE → HAI → histotripsy sequence. An upfront alternative chosen because of anatomy or organ reserve is not a post-progression second line. Bridge, downstaging and conversion preserve a later resection opportunity; conversion treatment is not itself the curative operation.
The tiers below are a clinical synthesis of treatment intent. They are not the roadmap's A–D evidence grading system, and the two should not be read as equivalent.
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Retained because they are defensible practice here, but each rests on anatomy, physiology or consensus rather than comparative outcome data. Each requires prospective outcome tracking, and none should be quoted to a patient, a payer or a referring clinician as evidence based.
| What the roadmap says | What is actually known, and why it is kept |
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The tumour board model, the quality dashboard and the decisions that need local approval. These are stakeholder-derived operating requirements — evidence grade D by construction, local policy choices with no comparative outcome evidence. They are labelled Standard because the programme chose them, not because trials support them.
Every source behind the pathway, with a link straight into the TMC library resolver. This is a decision-focused evidence synthesis, not a systematic review; single-arm response data are never used here to infer superiority.