De-Escalation: Reducing Breast Cancer Treatments
Breast cancer researchers are often focused on finding new and better treatments and prevention strategies for the disease.
However, some breast cancer research has another goal: to reduce the amount and intensity of treatment patients receive, while maintaining equally good cancer outcomes.
This is a research area for Professor Julia White.
Professor White is a tenured Professor of Radiation Oncology and Koltz Sisters Chair for Cancer Research at The Ohio State University.
“I think it’s important for us as providers to clarify that de-escalation doesn’t mean we’re backing off on therapy,” said Professor White.
“It means we’re right sizing treatment.”
“For so long, breast conservation has automatically meant you’re going to get surgery, a lumpectomy and breast radiation.”
“But from our knowledge of breast cancer biology, certain patients can be cured, or their cancer control is completed by just having the surgery portion.”
Professor White said de-escalation can be incredibly beneficial for certain patients, but the issue is identifying those patients who can benefit from this ‘right-sizing’ of treatment.
However clinical trials which use multi-gene assays or genomic tests of breast cancer tissue, can help to identify biologically which patients are going to have a low event rate in the breast after breast conserving surgery.
This means some patients could safely avoid radiation therapy.
“You’ll always get a lower reduction in breast risk when you radiate.”
“But if your likelihood of recurrence is so low then adding the radiation for women might not give a meaningful difference to them.”
“So, as we de-escalate or right-size breast conservation, we’re going to see who needs both lumpectomy and radiation and who is OK with just a lumpectomy.”
“So, de-escalation is really for breast cancer that is hormone sensitive, stage one. Meaning the lymph nodes are negative, in women who are post-menopausal and committed to taking their endocrine therapy.”
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Professor Julia White explains that de-escalation is right-sizing treatments for patients. She explains how we can find out who needs more or less surgery as part of their breast cancer treatment.
Current Research Into The De-Escalation In Breast Conserving Therapy
There is an increasing number of de-escalation clinical trials, including the Breast Cancer Trials EXPERT clinical trial.
EXPERT is investigating whether a genomic test of breast cancer tissue can be used to identify women with early breast cancer who can safely avoid radiation therapy after breast cancer surgery and the potential side effects of this treatment.
Professor White said in the US, where she practices, there are two groups of de-escalation trials.
“One is really for post-menopausal stage one breast cancer, in patients who are between the ages of 50 and 70.”
“Over age 70, the approach is de-escalation.”
“Under the age of 70, between 50 and 70, the trials are really focused on using a multi-gene assay, using an immunohistochemistry assay or using recurrence score.”
This is how researchers can determine if a patient needs further treatment after surgery, like radiation therapy.
Why De-Escalation Research Is Important
Professor White said de-escalation trials are about investing in patient’s wellbeing.
“It’s maybe not the most scientifically sexy clinical trials, we’re not identifying a new targeted agent, but we need to know how to take care of women.”
“When you look at breast cancer screening studies, the most common breast cancer stage that is picked up at breast cancer screening is stage one.”
“So, over 50% of newly diagnosed breast cancers are stage one and most of these occur in post-menopausal women and most of them are hormone sensitive,” she said.
“So, the impact is tens of thousands of women annually.”
“So, it’s really incumbent on us right now to run clinical trials that we can guarantee the next generation that we’ll know how to take care of them and that’s what we’re doing by investing in de-escalation trials.”
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