A New Hierarchy of Research Evidence for Tumor Pathology: A Delphi Study to Define Levels of Evidence in Tumor Pathology

Richard Colling, Iciar Indave, Javier del Aguila, Ramon Cierco Jimenez, Fiona Campbell, Magdalena Chechlińska, Magdalena Kowalewska, Stefan Holdenrieder, Inga Trulson, Karolina Worf, Marina Pollán, Elena Plans-Beriso, Beatriz Pérez-Gómez, Oana Craciun, Ester García-Ovejero, Irmina Maria Michałek, Kateryna Maslova, Grzegorz Rymkiewicz, Joanna Didkowska, Puay Hoon TanNur Diyana Md Nasir, Nickolas Myles, Gabrielle Goldman-Lévy, Dilani Lokuhetty, Ian A. Cree

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


The hierarchy of evidence is a fundamental concept in evidence-based medicine, but existing models can be challenging to apply in laboratory-based health care disciplines, such as pathology, where the types of evidence and contexts are significantly different from interventional medicine. This project aimed to define a comprehensive and complementary framework of new levels of evidence for evaluating research in tumor pathology—introducing a novel Hierarchy of Research Evidence for Tumor Pathology collaboratively designed by pathologists with help from epidemiologists, public health professionals, oncologists, and scientists, specifically tailored for use by pathologists—and to aid in the production of the World Health Organization Classification of Tumors (WCT) evidence gap maps. To achieve this, we adopted a modified Delphi approach, encompassing iterative online surveys, expert oversight, and external peer review, to establish the criteria for evidence in tumor pathology, determine the optimal structure for the new hierarchy, and ascertain the levels of confidence for each type of evidence. Over a span of 4 months and 3 survey rounds, we collected 1104 survey responses, culminating in a 3-day hybrid meeting in 2023, where a new hierarchy was unanimously agreed upon. The hierarchy is organized into 5 research theme groupings closely aligned with the subheadings of the WCT, and it consists of 5 levels of evidence—level P1 representing evidence types that merit the greatest level of confidence and level P5 reflecting the greatest risk of bias. For the first time, an international collaboration of pathology experts, supported by the International Agency for Research on Cancer, has successfully united to establish a standardized approach for evaluating evidence in tumor pathology. We intend to implement this novel Hierarchy of Research Evidence for Tumor Pathology to map the available evidence, thereby enriching and informing the WCT effectively.

Original languageEnglish
Article number100357
JournalModern Pathology
Issue number1
StatePublished - Jan 2024


  • classification
  • evidence based
  • hierarchy
  • histopathology
  • pathology
  • tumor


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