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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.
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).
Platinum and immunotherapy are now consensus for early triple-negative disease; the open votes have moved to who can safely receive less.
The evidence behind the stage I de-escalation statement on the triple-negative page: an ordinary haematoxylin and eosin slide identifies a fifth of patients whose outcome without chemotherapy matches treated cohorts. A prospective trial of chemotherapy omission is the missing step.
St Gallen is where de-escalation questions in triple-negative disease (who needs the full KEYNOTE-522 regimen, who can skip adjuvant pembrolizumab) are first put to a vote; the 2023 panel framed intensity and duration as the central problem.
Shares DYNAMIC-III, CIRCULATE-US, CIRCULATE-Japan (GALAXY / VEGA / ALTAIR), DYNAMIC.
Shares NeoPACT, Give exceptional responders less: pembrolizumab omission after complete response, anthracycline-free regimens and chemotherapy omission in lymphocyte-rich stage I disease, KEYNOTE-522, Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem.
Shares DYNAMIC-III, CIRCULATE-US, CIRCULATE-Japan (GALAXY / VEGA / ALTAIR), DYNAMIC.
Shares 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, 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, Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer, Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem.
Shares Give exceptional responders less: pembrolizumab omission after complete response, anthracycline-free regimens and chemotherapy omission in lymphocyte-rich stage I disease, KEYNOTE-522, Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem, Triple-negative breast cancer trials open today (registry snapshot and UK sites).
Shares DYNAMIC-III, CIRCULATE-US, ctDNA tests roadmap: from a curiosity in plasma to blood tests that decide treatment, Circulating tumour DNA (ctDNA).
Shares Residual disease after neoadjuvant therapy in triple-negative breast cancer: the decision point, KEYNOTE-522, Circulating tumour DNA (ctDNA), Triple-negative breast cancer trials open today (registry snapshot and UK sites).
Shares 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, 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, Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem, Triple-negative breast cancer (TNBC).