{"entity":{"id":"de-escalation","kind":"term","name":"De-escalation, escalation and response-adapted therapy","aka":["de-escalation","de-escalate","de-escalated","de-escalating","de-intensification","de-intensify","treatment de-escalation","treatment intensification","intensification","response-adapted","response-guided","risk-adapted","risk-adapted therapy","biomarker-guided","ctDNA-guided","MRD-guided","PET-adapted","omission of chemotherapy","chemotherapy omission","chemotherapy-free","chemo-free","less is more","treatment omission"],"tldr":"Giving less treatment to patients who are doing well and more to those who are not, using a marker such as scan response, ctDNA or MRD to decide. The aim is to cure the same number of people with less harm.","summary":"Examples: omitting chemotherapy in low-risk HR-positive breast cancer by genomic assays (TAILORx, MINDACT) or in HER2-positive disease by PET response (PHERGain); shortening adjuvant FOLFOX to 3 months (IDEA); ctDNA-guided omission or escalation of adjuvant chemotherapy in colon cancer (DYNAMIC, CIRCULATE); PET-guided omission of radiotherapy or bleomycin in lymphoma; 12 versus 6 months of trastuzumab (PERSEPHONE); radiotherapy dose reduction in HPV-positive oropharynx cancer (which has repeatedly failed); and MRD-guided stopping in CLL and myeloma. De-escalation trials need non-inferiority designs and large numbers, and are rarely funded by industry. Escalation trials add drugs to non-responders (KEYNOTE-522 residual disease, CheckMate 577).","asOf":"2026-09-09","links":[{"label":"ClinicalTrials.gov NCT03036488: KEYNOTE-522","url":"https://clinicaltrials.gov/study/NCT03036488"},{"label":"ClinicalTrials.gov NCT02743494: CheckMate 577","url":"https://clinicaltrials.gov/study/NCT02743494"}],"tags":[],"related":["non-inferiority","deauville","umrd","ctdna","organ-preservation"],"cancers":[],"sections":["chemotherapy"],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":["dynamic","circulate-japan","keynote-522","checkmate-577"],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"category":"Treatment jargon","wikipediaChecked":"2026-09-22"},"route":"/terms/de-escalation/","neighbours":{"term":[{"id":"abvd-beacopp","kind":"term","name":"ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens)","route":"/terms/abvd-beacopp/"},{"id":"backbone-add-on","kind":"term","name":"Backbone, add-on and monotherapy","route":"/terms/backbone-add-on/"},{"id":"ctdna","kind":"term","name":"Circulating tumour DNA (ctDNA)","route":"/terms/ctdna/"},{"id":"deauville","kind":"term","name":"Deauville score and PET-adapted therapy","route":"/terms/deauville/"},{"id":"late-effects","kind":"term","name":"Late effects and survivorship toxicity","route":"/terms/late-effects/"},{"id":"non-inferiority-margin","kind":"term","name":"Non-inferiority margin and equivalence trials","route":"/terms/non-inferiority-margin/"},{"id":"non-inferiority","kind":"term","name":"Non-inferiority trial","route":"/terms/non-inferiority/"},{"id":"organ-preservation","kind":"term","name":"Organ preservation (watch-and-wait, bladder-sparing, larynx preservation)","route":"/terms/organ-preservation/"},{"id":"tnbc-residual-disease-decision","kind":"term","name":"Residual disease after neoadjuvant therapy in triple-negative breast cancer: the decision point","route":"/terms/tnbc-residual-disease-decision/"},{"id":"smart-design","kind":"term","name":"SMART design (sequential multiple assignment randomised trial)","route":"/terms/smart-design/"},{"id":"stepped-wedge-design","kind":"term","name":"Stepped-wedge design","route":"/terms/stepped-wedge-design/"},{"id":"tnbc-trials-open-today","kind":"term","name":"Triple-negative breast cancer trials open today (registry snapshot and UK sites)","route":"/terms/tnbc-trials-open-today/"},{"id":"umrd","kind":"term","name":"Undetectable MRD (uMRD / MRD-negative)","route":"/terms/umrd/"}],"section":[{"id":"chemotherapy","kind":"section","name":"Chemotherapy","route":"/fronts/chemotherapy/"}],"trial":[{"id":"checkmate-577","kind":"trial","name":"CheckMate 577","route":"/trials/checkmate-577/"},{"id":"circulate-japan","kind":"trial","name":"CIRCULATE-Japan (GALAXY / VEGA / ALTAIR)","route":"/trials/circulate-japan/"},{"id":"circulate-us","kind":"trial","name":"CIRCULATE-US","route":"/trials/circulate-us/"},{"id":"acns0331","kind":"trial","name":"COG ACNS0331","route":"/trials/acns0331/"},{"id":"aren0533","kind":"trial","name":"COG AREN0533","route":"/trials/aren0533/"},{"id":"dynamic","kind":"trial","name":"DYNAMIC","route":"/trials/dynamic/"},{"id":"dynamic-iii","kind":"trial","name":"DYNAMIC-III","route":"/trials/dynamic-iii/"},{"id":"idea-collaboration","kind":"trial","name":"IDEA collaboration","route":"/trials/idea-collaboration/"},{"id":"keynote-522","kind":"trial","name":"KEYNOTE-522","route":"/trials/keynote-522/"},{"id":"neopact","kind":"trial","name":"NeoPACT","route":"/trials/neopact/"},{"id":"scot","kind":"trial","name":"SCOT","route":"/trials/scot/"}],"cancer":[{"id":"tnbc","kind":"cancer","name":"Triple-negative breast cancer (TNBC)","route":"/cancers/tnbc/"}],"paper":[{"id":"paper-st-gallen-2025-consensus-ann-oncol-2025","kind":"paper","name":"Tailoring treatment to cancer risk and patient preference: the 2025 St Gallen International Breast Cancer Consensus Statement on individualizing therapy for patients with early breast cancer","route":"/key-papers/paper-st-gallen-2025-consensus-ann-oncol-2025/"},{"id":"paper-leon-ferre-tils-tnbc-no-chemotherapy-jama-2024","kind":"paper","name":"Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer","route":"/key-papers/paper-leon-ferre-tils-tnbc-no-chemotherapy-jama-2024/"},{"id":"paper-st-gallen-2023-consensus-ann-oncol-2023","kind":"paper","name":"Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023","route":"/key-papers/paper-st-gallen-2023-consensus-ann-oncol-2023/"}],"roadmap":[{"id":"ctdna-tests","kind":"roadmap","name":"ctDNA tests roadmap: from a curiosity in plasma to blood tests that decide treatment","route":"/roadmaps/ctdna-tests/"},{"id":"tnbc-roadmap","kind":"roadmap","name":"Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem","route":"/roadmaps/tnbc-roadmap/"}],"idea":[{"id":"idea-gbc-ctdna-residual-disease-guided-adjuvant-trial","kind":"idea","name":"A ctDNA residual disease-guided adjuvant trial after gallbladder cancer resection","route":"/ideas/idea-gbc-ctdna-residual-disease-guided-adjuvant-trial/"},{"id":"idea-gbc-t2a-spare-liver-resection-trial","kind":"idea","name":"A trial of sparing the liver resection in peritoneal-side (T2a) gallbladder cancer","route":"/ideas/idea-gbc-t2a-spare-liver-resection-trial/"},{"id":"idea-tnbc-de-escalation-for-exceptional-responders","kind":"idea","name":"Give exceptional responders less: pembrolizumab omission after complete response, anthracycline-free regimens and chemotherapy omission in lymphocyte-rich stage I disease","route":"/ideas/idea-tnbc-de-escalation-for-exceptional-responders/"},{"id":"idea-gbc-t1b-simple-cholecystectomy-prospective-study","kind":"idea","name":"Test whether T1b gallbladder cancer needs the second operation at all","route":"/ideas/idea-gbc-t1b-simple-cholecystectomy-prospective-study/"}],"person":[{"id":"david-palma","kind":"person","name":"David A. Palma","route":"/people/david-palma/"},{"id":"jeffrey-dome","kind":"person","name":"Jeffrey S. Dome","route":"/people/jeffrey-dome/"}],"journal":[{"id":"jama-internal-medicine","kind":"journal","name":"JAMA Internal Medicine","route":"/journals/jama-internal-medicine/"}]}}