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(CNN) — Almost all of Dr. Ursina Teitelbaum’s colorectal cancer patients worry: How serious are the side effects of radiation therapy? Although cancer treatment is effective, it can cause diarrhea and fatigue in the short term, as well as fertility problems in the long term.
But above all, people want to survive cancer, and new research suggests that reducing the intensity of these treatments may not affect patients’ chances of survival.
With this clearer data, it seems that more and more oncologists are reducing the use of invasive or inconvenient therapies based on the quality of life of their patients, a measure that is described as a de-escalation.
For example, in the case of rectal cancer, chemotherapy, radiation therapy, and surgery are often the three main components of treatment plans, unless the patient is eligible for a de-escalation approach in which one or more of these treatments can be safely excluded. .
“I tell patients, ‘I want you to live longer, but I also want you to live better,'” explains Teitelbaum, an oncologist who specializes in pancreatic and colorectal cancer at Penn Medicine.
“Sometimes we can give chemo vacation for two or three months. Patients love chemo vacation and then we can extend it again without compromising the outcome for the patient. Basically, it can prevent side effects,” Explain. “So what can we do to reduce the focus of his therapy so that he not only lives longer, but also feels better? This is the goal.” However, he added that his patients are often “very concerned” about the de-escalation approach.
Sometimes less is more
When Alex Wood was diagnosed with cancer about three years ago, his first thought was to do everything possible to treat it.
“You don’t think much about quality of life,” says Wood, who lives in Pennsylvania.
He went through what he describes as a “normal” colorectal cancer treatment plan: about eight rounds of chemotherapy and then surgery to remove the tumor. This was in June 2020. But about six months later, additional traces of cancer were found in Wood’s liver and lungs.
“So since then I’ve had six surgeries mostly to remove these nodules. And I had about 50 chemotherapy sessions, give or take, like radiation therapy, ”explains Wood.
During all these intravenous infusions of chemotherapy and radiation, this 46-year-old enthusiastic climber experienced severe nausea and fatigue.
To mitigate these side effects, Teitelbaum, who treated him at Penn Medicine, proposed a de-escalation method that would remove two drugs from his three-drug regimen. Wood agreed and is now doing well and is back climbing regularly at the gym.
“Over the course of four to five months, we gradually tapered off the medication so that I now only take one and the side effects have decreased significantly, to the point where I can now exercise the day after taking the medication,” he explains. Wood. “As far as I understand, 20 years ago people couldn’t live their lives with treatment.”
Alex Wood, 46, was diagnosed with colorectal cancer three years ago and says he is doing well with the “de-escalation” approach to treatment. Credit: Courtesy of Avi Fox Photography
Teitelbaum is among the oncologists who practice finding a balance: reducing the intensity of anticancer therapy while ensuring that patients continue to receive optimal treatment.
“We are correcting everything. We learn when we can give less,” he says. “Sometimes less is more because all these treatments are very toxic.”
More bad than good?
De-escalation describes cases where optimal care can be achieved with less than more treatment. A growing number of studies, including several presented in June at the annual meeting of the American Society of Clinical Oncology, suggest that this approach may be useful for certain types of cancer.
An advanced-stage study in women with cervical cancer found that the risk of cancer progression was low after a simple hysterectomy, in which only the uterus and cervix were surgically removed. The results were similar to those obtained after a more aggressive radical hysterectomy, which removes the surrounding parts of the cervix, part of the vagina and some tissues and ligaments in this area, as well as the uterus.
Another study on the treatment of rectal cancer found that among more than 1,000 patients, those who received chemotherapy alone before surgery had similar outcomes in terms of survival and recurrence as those who received chemotherapy plus radiotherapy.
The results show that in some cases patients with rectal cancer can do without radiation, which can have side effects in the treatment area, such as fertility problems after pelvic radiation therapy.
“We have been using chemoradiotherapy since the 1990s because it has proven to be extremely effective in reducing the rate of local recurrence in the pelvis,” gastrointestinal oncologist Dr. Deb Schrag, chief of medicine at Memorial Sloane. Kettering Cancer Center and first author of this study.
“My colleagues and I began to see more young women with rectal cancer who were devastated not only because they had cancer, but also because the standard treatment we had to offer them would mean they couldn’t carry the pregnancy to term,” Schrag said. . “That was one of the important reasons we were looking for a way to help patients and see if we could achieve favorable results without the uniform application of radiation.”
The study is just one example of de-escalation and how “less is more” in some cases, said Dr. Paul Oberstein, a medical oncologist at New York University’s Langone Perlmutter Cancer Center, who was not involved in the study.
“This is a perfect example of less is more. One group had two things: surgery and chemotherapy, and the other group had three things: surgery, chemotherapy and radiotherapy, and you can avoid the potential complications of radiotherapy because you just miss it. We think this is a very favorable trend.” Oberstein says.
“The good news is that it does not increase the risk of death, which is obviously the main endpoint, or local cancer recurrence in this area of the rectum. we will see a signal in 10 or 20 years. We have to watch it,” he said.
Another study suggests that for some people with early-stage breast cancer, easier treatment with targeted drug therapy was associated with improved survival and was comparable to treatment with chemotherapy.
And earlier this year, results from a long-term British study showed that men who collaborated with their doctors to closely monitor their low-to-moderate-risk prostate tumors, a strategy called surveillance or active follow-up, avoided life. – reversal of complications such as urinary incontinence and erectile dysfunction, but they are no more likely to die from cancer than men who have undergone prostate surgery or have been treated with hormone blockers and radiation.
“The problem with cancer treatment is that drugs can cause side effects by damaging healthy cells or organs,” says Dr. Tatjana Kolewska, medical director of Kaiser Permanente’s National Cancer Treatment Improvement Program.
“With cancer, the fear and anxiety is huge, so very often we use more, which can make people very sick. We want to try everything to cure the patient, but in some cases, too aggressive treatment can do more harm than good,” he said. said.
Not all patients want the same
For years, scholars have called for more research into the risks and benefits of de-escalation. In 2014, an article published in the Cochrane Database of Systematic Reviews analyzed data on de-escalation protocols for the treatment of oral and throat cancers associated with human papillomavirus (HPV) infections. The data showed that for these cancers, “there is not enough high-quality evidence for or against treatment de-escalation.”
But it’s still well known that HPV-related cervical cancer is far more curable than non-HPV-related cancer, said Dr. Lori Wirth, medical director of the Head and Neck Cancer Center at the Massive General Cancer Center in Boston. did not participate in the Cochrane Review.
“Thus, patients with HPV-related disease will have a slightly different approach compared to those without HPV,” Wirth said, referring to the personalized approach to de-escalation.
“One of the things we’re doing right now is trying to be smart about identifying patients that can be de-escalated and still be fine. Not all patients want the same thing and I think it’s our job as clinicians to make sure that when there isn’t a one-size-fits-all approach, when there are options, we help the patient explore those options and make sure we’re on the path that’s most appropriate. for this particular patient,” he said.
Young cancer patients are particularly interested in de-escalating treatment approaches. In addition, studies are emerging highlighting the benefits of this type of treatment, with an increasing number of young people being diagnosed with certain types of cancer, such as colorectal.
The rate of colorectal cancer diagnoses among adults younger than 55 in the United States has been on the rise since the 1990s. A report published in March by the American Cancer Society shows that the rate of colorectal cancer among adults in this age group has increased since age 11. % in 1995 to 20% in 2019.
Colorectal cancer is “anxious in younger patients,” and many require less stringent approaches to their treatment, says Dr. Aparna Parikh, a gastrointestinal oncologist at the Mass Cancer Center.
“You would think that more and more people would say, ‘I don’t want to exclude anything at all, give it all to me,’” he said. “But people need this approach, and we advise them the most on the pros and cons. So that’s what we use and carefully discuss.”
Some colorectal cancer surgeries can leave a person with a bag, called an ostomy pouch, surgically attached to the abdomen to collect waste passing through the intestines. “A permanent stoma is life changing,” Parikh says.
But in some cases, “with a couple of doses of immunotherapy, the tumors completely disappeared, and they did not need radiation therapy. They didn’t need surgery. You have to keep watching people closely if you’re going to do without surgery.” or no radiation, but I think it’s interesting now to really choose which patients may or may not benefit from each of those options,” he said. “But at the same time, you have to understand that each tumor has its own nuances in each patient.”
