What is De-escalation Treatment in Cancer Research?

May 30, 2023
Jyoti Patel, MD, FASCO

When we think of cancer research, we often think of new treatments, new combinations of different drugs, or new tests to diagnose disease. We have been conditioned to think that more treatment should always be better, even if that treatment also causes more side effects. When faced with a cancer diagnosis, a person’s first instinct is often that they want to try everything possible to cure or treat the cancer. However, aggressive treatment sometimes brings side effects that can impact a person’s quality of life, including by causing some lingering effects that might not go away with time. Researchers are now understanding that perhaps everyone doesn’t need the same intensity of cancer therapy.

As cancer medicine has become more advanced and as we’ve learned much more about how and why cancer grows and spreads, we have the opportunity to consider a more nuanced and personalized approach to treatment. With this, there is substantial research being done in how we can “de-escalate” cancer treatment, meaning how we can reduce the intensity or duration of treatment without compromising survival and perhaps even improving quality of life.

Fundamentally, studying de-escalation treatment approaches mean that we’re evaluating the idea of giving less rather than giving more. It could mean cutting back on the number of chemotherapy drugs given or even eliminating chemotherapy altogether. It could mean reducing the extent of surgery or eliminating radiation therapy from the treatment plan. It could mean shortening how long therapy lasts or simplifying a treatment regimen in some other way. It is important that we carefully and scientifically study when it is possible to give less therapy because we don’t want to undermine our shared goal of trying to cure the disease and help people live longer.

Examples of de-escalation treatment have been emerging ever more frequently in cancer research, including in research that will be presented at this year’s ASCO Annual Meeting. At last year’s ASCO Annual Meeting, for instance, one study found that using liquid biopsy, which uses a blood sample to evaluate the amount of cancer DNA in a person’s blood, could help people with stage II colon cancer avoid receiving unnecessary chemotherapy after surgery if no cancer DNA was found in their blood, without increasing the risk of the cancer coming back.

Now that we have a greater understanding of the different subtypes of cancer, we also know that not everyone should receive the same cancer treatment. Instead, based on the tumor’s molecular features and thanks to enhanced radiologic imaging, better understanding of side effects, and more precise therapies, we are able to better tailor treatment to the individual. Because of this, some people think an even better term for de-escalation treatment is “optimization of therapy.” And that’s exactly what we’re trying to do: optimize the treatment to still effectively cure cancer and reduce side effects, both in the short and long term.

When you have cancer, we know that you don’t want to experience unnecessary side effects. However, the concept of de-escalating treatment may still be difficult to grapple with. For some people, the fear of cancer recurrence may make them feel uncomfortable because the idea of not doing the maximum amount of treatment may mean that the cancer could come back. Understanding why your cancer doctor is recommending a particular treatment plan may help ease your fears.

The goal of cancer therapy has long been about improving survival. But now, with better tools and a deeper understanding of cancer science, we can focus on the quality of life during survival, too. As we look to the future, it's important that we focus on delivering the best possible individualized care to people with cancer using precision medicine at all levels, so we can prioritize the best outcomes.

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