{"entity":{"id":"idea-fund-omission-deescalation-trials","kind":"idea","name":"Payer-funded trials that omit surgery or radiotherapy in low-risk patients","aka":[],"tldr":"Low-risk patients often receive operations and radiotherapy they may not need, for example sentinel node biopsy in older women with favourable breast cancer or radiotherapy after breast-conserving surgery in genomically low-risk disease. Because no company will sponsor trials of leaving treatment out, health systems should fund them and keep the savings.","summary":"Payers and public funders sponsor randomised trials of omission or de-escalation of local therapy: omitting sentinel node biopsy in older women with favourable breast cancer (as SOUND and INSEMA tested), omitting radiotherapy after breast-conserving surgery in genomically low-risk disease, active surveillance instead of surgery in low-risk thyroid and prostate cancer, and shorter or lower-dose regimens. These trials save money, reduce harm and address overdiagnosis, but have no commercial sponsor. Genomic and imaging biomarkers now allow risk-adapted selection that makes omission trials ethically and statistically feasible.","asOf":"2026-09-08","links":[{"label":"Bottleneck evidence (Surgery and radiotherapy cure most, get least): Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015)","url":"https://doi.org/10.1016/S1470-2045(15)00223-5"}],"tags":[],"related":["idea-fund-organ-preservation-programme","idea-fund-payer-funded-pragmatic-trials","idea-til-guided-deescalation"],"cancers":["breast-hr-positive","thyroid","prostate"],"sections":[],"technologies":["sentinel-node","imrt-igrt"],"targets":[],"drugs":["oncotype-dx"],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":["b-surgery-radiation-innovation","b-toxicity-qol","b-overdiagnosis"],"keyPapers":["paper-sullivan-lancet-oncol"],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"A payer-funded omission programme produces at least four practice-changing results within six years, each reducing the number of procedures or radiotherapy courses in the target population by a fifth or more with non-inferior recurrence.","rationale":"SOUND, INSEMA, PRIME II and the low-risk DCIS trials have shown omission is safe in defined groups and changed guidelines; each was funded with difficulty by academic grants. Payers are the natural sponsors because the savings accrue to them directly.","test":"A payer trials fund launches two omission trials and pre-registers projected savings; audit realised savings and outcome non-inferiority at trial completion.","maturity":"being-tested-at-scale","actor":"payer","cost":"medium","horizonYears":4},"route":"/ideas/idea-fund-omission-deescalation-trials/","neighbours":{"idea":[{"id":"idea-fund-organ-preservation-programme","kind":"idea","name":"A funded programme of organ-preservation trials to avoid radical surgery","route":"/ideas/idea-fund-organ-preservation-programme/"},{"id":"idea-fund-payer-funded-pragmatic-trials","kind":"idea","name":"Payers fund trials of cheaper, shorter or lower-dose versions of expensive treatments","route":"/ideas/idea-fund-payer-funded-pragmatic-trials/"},{"id":"idea-til-guided-deescalation","kind":"idea","name":"TIL-based omission of chemotherapy in stage I TNBC","route":"/ideas/idea-til-guided-deescalation/"}],"cancer":[{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"},{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"},{"id":"thyroid","kind":"cancer","name":"Thyroid cancer","route":"/cancers/thyroid/"}],"technology":[{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"sentinel-node","kind":"technology","name":"Sentinel lymph node biopsy","route":"/technologies/sentinel-node/"}],"drug":[{"id":"oncotype-dx","kind":"drug","name":"Oncotype DX","route":"/drugs/oncotype-dx/"}],"bottleneck":[{"id":"b-overdiagnosis","kind":"bottleneck","name":"Overdiagnosis and false alarms","route":"/bottlenecks/b-overdiagnosis/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}],"paper":[{"id":"paper-sullivan-lancet-oncol","kind":"paper","name":"Global cancer surgery: delivering safe, affordable, and timely cancer surgery","route":"/key-papers/paper-sullivan-lancet-oncol/"}]}}