De-escalation was a theme explored multiple times across the duration of the recent Miami Breast Cancer Conference. One speaker who took up the topic was Rakesh Patel, MD, Program Chair for Breast Cancer Services at Eden Medical Center in Castro Valley, CA.
In a presentation titled “Balancing De-Escalation Across Modes of Therapy,” Dr. Patel addressed the meaning of the term “de-escalation” and spoke about its application in surgery, radiation therapy, and systemic therapy, as well as the movement’s recent history.
What does “de-escalation” mean?
How do we—or should we—define “de-escalation?” Dr. Patel asked his audience. He offered these possibilities:
- A way to improve physical quality of life for patients.
- Taking steps to minimize aggressive and radical surgery, to reduce or even omit radiotherapy, and to forgo systemic chemotherapy in select estrogen receptor-positive patients.
- Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care.
Adding more detail to the discussion of a definition, Dr. Patel turned for support to Choosing Wisely®, an initiative of the American Board of Internal Medicine Foundation. Choosing Wisely® was created to advance “a national dialogue on avoiding unnecessary medical tests, treatments and procedures,” according to its website. In addressing treatment of breast cancer, Choosing Wisely® lists recommendations from the American College of Surgeons (ACS), the American Society of Breast Surgeons (ASBrS), the American Society of Clinical Oncology (ASCO), the Society of Surgical Oncology (SSO), and the American Society for Therapeutic Radiology (ASTRO), all of which Dr. Patel shared:
- Don’t routinely perform a double mastectomy in patients who have a single breast with cancer. (ASBrS)
- Don’t routinely use sentinel node biopsy in clinically node negative women >70 years of age with early stage hormone receptor positive, HER2 negative invasive breast cancer. (SSO)
- Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy. (ACS)
- Don’t routinely order specialized tumor gene testing in all new breast cancer patients. (ASBrS)
- Don’t use combination cytotoxic chemotherapy (multiple drugs) instead of chemotherapy with one drug when treating an individual metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms. (ASCO)
- Don’t initiate whole breast radiotherapy as part of breast conservation therapy in women with early stage invasive breast cancer without considering shorter treatment schedules. (ASTRO)
De-escalation in practice.
Dr. Patel then focused, in turn, on de-escalation in each of three modes of therapy: Surgery, radiation, and systemic therapy.
In the practice of surgery, the paradigm shifts have included the decline of mastectomy in favor of breast-conserving surgery and the decline of axillary surgery in favor of sentinel lymph node biopsy (SLNB). De-escalation in radiation therapy has been marked by a shift from standard fractionation whole breast radiotherapy (RT) to hypofractionated whole breast RT and whole breast RT to partial breast RT, Dr. Patel noted. De-escalation in systemic therapy, finally, is evident in the shift from chemotherapy in tumors of >1 cm as standard course of action to tailored treatment plans and from adjuvant therapy to consideration of neoadjuvant therapy.
In concluding, Dr. Patel noted that across all modalities, “statistical significance does not always mean clinical significance, toxicity and quality of life are important considerations, and treatment has to be personalized.”