Less is more is not an expression commonly associated with cancer treatment. In fact, when facing a cancer diagnosis, many people believe the opposite: doctors should not only do more, but do everything in their power to eradicate their patients’ cancer. But aggressive treatment often leads to challenging side effects – both short- and long-term – that can make life difficult. And researchers are learning that not all patients with cancer need the same level, or even the same type, of treatment. Some patients, especially those with early-stage cancers, may respond just as well to less treatment – which in turn reduces their risk of side effects.
As cancer medicine improves and becomes more advanced, researchers now want to tailor therapy to individuals, rather than using a one-size-fits-all approach. For some patients, this may mean de-escalating treatment, or reducing its intensity. Importantly, though, de-escalation does not mean reducing cure rates or how well patients respond.
Below, Gabrielle Rocque, MD (pictured), a medical oncologist at the University of Alabama at Birmingham Cancer Center, shares her expertise regarding treatment de-escalation and why it is an important concept to study in cancer clinical trials.
What does de-escalation, or de-intensification, mean when talking about cancer treatment?
De-escalation is an effort to reduce the intensity of treatment without sacrificing efficacy. Cancer researchers have developed therapies over time with an approach that, in general, adds additional treatments each time. However, some of those new treatments come at the cost of side effects for patients. In order to get the right therapies to the right patients, we have to be able to understand how we can safely and effectively both add treatments and take them away. Ultimately, we want to find the best approach for treating a patient for their specific cancer.
Can de-escalation also be described as “optimizing” treatment?
The concepts of both optimization and personalization are often tied to de-escalation. In most cases, we are using some type of data – whether that is the patient’s initial response to treatment, the stage of their cancer, or something simple like their age – to help determine if the benefit of reducing or removing a treatment may outweigh the potential risk. Generally, patients considered for de-escalation studies already have an excellent prognosis, and the most likely outcome is that they will do exceptionally well.
What are some of the challenges that arise when talking about de-escalation?
De-escalation has a number of challenges. One is that patients have a fear of cancer, so for many people the idea of not doing the absolute maximum amount of treatment makes them uncomfortable, because they are worried about their cancer coming back. Another issue is that this type of work represents a paradigm shift. Historically, the conversation with patients has been, “We are going to add this additional treatment to try and do better.” That is an easy concept for people to embrace.
The conversation is different when you are looking at de-escalation. It requires more explanation on the part of the clinical team, to review the background behind the usual treatment approach and talk through why we want to reduce treatment. I think the “why” is very important to patients – it helps them fully appreciate that these efforts are in their best interest.
Why is it important to study de-escalation in cancer clinical trials?
At the end of the day, we would love to get to a point where we can see a patient and, based on who they are, their medical history, and their specific cancer, provide the ideal treatment that will result in the fewest side effects and the best outcome. In order to get to that point – where we have a truly personalized, individualized approach – we need to learn when it is safe to scale back treatment. Otherwise, we will never find the best strategy for each individual patient.
This work does need to be done in the clinical trial setting, though. De-escalation is something we need to study – physicians cannot just start giving less intense treatment without rigorous testing. Patients are monitored very closely when they participate in clinical trials, so if a less intensive approach does not work for them, they often can go on to receive more treatment.
This issue of Considering Clinical Trials highlights several ECOG-ACRIN de-escalation studies – including DECREASE (anal cancer), CompassHER2 pCR (breast cancer), and E3311 (throat cancer) – and explores how they may lead to improvements in patient care.