De-escalating Cancer Therapy: More Talk Than Action?

Ravi Parikh, MD, MPP, writes in Medscape:

"The prevailing bias among oncologists to offer more, rather than less, treatment if it provides a chance of benefit further complicates the discussion.

The most obvious elephant in the room is that large randomized trials need to be funded. It is much easier to fund an escalation trial than to fund a de-escalation trial. Will the National Institutes of Health, Agency for Healthcare Research and Quality, or private companies step up to fund de-escalation? So far, the answer is a resounding no.

Beyond funding, there are other ways to correct the trend against de-escalation. Better reporting of patient-reported outcomes and long-term side effects of intensified therapies will clarify the benefits they truly offer. As new treatments in later-line diseases become available, the relative efficacy of intensified first-line therapies must be reconsidered.

But perhaps most important, we need a better rationale for intensifying up-front therapy. And we need to realize that de-intensifying therapies is difficult. Maybe future trials could add treatment arms with options for therapy with decreased durations or lower doses of intensive therapy. Finally, we ought to be able to use real-world data to track in real-time whether different, lower-intensity treatment strategies can be effective.

Ultimately, a better balance between escalation and de-escalation can increase the likelihood that patients are only getting just as much therapy as they need—nothing more and nothing less. And as oncologists, we'd finally be doing more than simply talking the talk when it comes to de-escalating treatments for our patients."