The trend toward 'de-escalated' cancer treatments, explained

A cancer diagnosis can be terrifying, not just because the disease is life-threatening but also because treatments — chemotherapy, radiation and surgery — are often brutal to endure. But doctors are now rethinking those aggressive methods, The Wall Street Journal reported. They're increasingly looking to "de-escalation," an approach of "cutting back on some therapies to improve a patient's quality of life without hurting their odds of survival."

One new study shows that more than 10,000 rectal cancer patients a year could forgo radiation therapy and do just as well, The New York Times reported, though they would still need chemotherapy and surgery. Dr. Eric Winer, the president of the American Society of Clinical Oncology (ASCO), said researchers "are asking if there are elements of successful treatments that can be eliminated to provide patients with a better quality of life."

What is de-escalation in cancer treatment?

"Fundamentally, studying de-escalation treatment approaches mean that we're evaluating the idea of giving less rather than giving more," wrote Dr. Jyoti Patel at Cancer.Net. Oncologists and patients have been "conditioned to think that more treatment should always be better," but aggressive treatment often comes with side effects that undermine the patient's quality of life. Chemotherapy and radiation can cause hair loss, fatigue and other side effects and induce new forms of cancers.

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The trend toward de-escalation is partly a recognition of those quality-of-life issues but also a matter of research advances. Thanks to a better understanding of how cancer works, doctors can take a "more nuanced and personalized approach to treatment" instead of throwing everything at the wall. "The goal of cancer therapy has long been about improving survival," Patel wrote, but "we can focus on the quality of life during survival, too."

Where has de-escalation proved promising?

The rectal cancer findings are just the latest in a series of studies on de-escalated therapies. A 2022 study found that some breast cancer patients, for whom treatment typically includes surgery, chemotherapy and radiation treatment, may not need surgery to improve. Testicular cancer patients may also benefit from reduced chemotherapy and radiation treatments, according to results published in November. Another study presented this week at an ASCO conference found laparoscopic surgery worked as well for some pancreatic cancer patients as did more invasive surgical options.

A recent clinical trial found the same rate of "cancer control" in some early-stage cervical cancer patients who received a "simple" hysterectomy (removal of the uterus) as with a radical hysterectomy (removal of the uterus, cervix and surrounding tissue). The findings are likely to be "practice-changing," said Dr. Marie Plante at Laval University in Quebec.

What do patients say?

It's complicated. A survey published in the Journal of Clinical Oncology found that a small group of breast cancer patients were interested in de-escalated therapy for their illness, as long as the word "de-escalation" wasn't used by doctors. It sounded to them like the doctors were giving up on treatment. So instead oncologists speak in terms of "personalized" care. Patients are more inclined to participate in de-escalated treatments, the researchers found, "if they are framed in terms of customizing treatment to the individual patient and added benefit — reduced toxicities, higher quality of life during treatment, and lower risk of long-term complications — rather than in terms of taking treatments away or doing less than the standard of care."

For some slow-moving cancers, though, patients appear to be fine with fewer aggressive treatments. An April study in JAMA Internal Medicine found that 60% of low-risk prostate cancer patients are opting for "advanced surveillance" of their cancer rather than surgery or radiation, up from 16% in 2010. "These data show that a diagnosis of prostate cancer no longer means a patient will undergo treatment," said Dr. Jonathan Shoag of the Seidman Cancer Center in Cleveland. "We now can, and do, avoid treating cancers that we believe will behave indolently."

What's next?

The trend toward de-escalation will continue. Federal regulators this year issued new guidance to cancer drug developers on how to determine dosages, The Wall Street Journal reported. Previously, "doses were traditionally set at the highest tolerable amount." Now those drugmakers are looking for the "best balance between efficacy and safety," said Tara Frenkl, a senior vice president for Bayer. "That's a relatively new concept for oncology."